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Dutra KJ, Lazenby GB, Goje O, Soper DE. Cefazolin as the mainstay for antibiotic prophylaxis in patients with a penicillin allergy in obstetrics and gynecology. Am J Obstet Gynecol 2024; 231:430-436. [PMID: 38527607 DOI: 10.1016/j.ajog.2024.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/20/2024] [Accepted: 03/13/2024] [Indexed: 03/27/2024]
Abstract
Cefazolin is the most common antibiotic used for prophylaxis in obstetrics and gynecology. Among those with a penicillin allergy, alternative antibiotics are often chosen for prophylaxis, given fears of cross-reactivity between penicillin and cefazolin. Alternative antibiotics in this setting are associated with adverse sequelae, including surgical site infection, induction of bacterial resistance, higher costs to the healthcare system, and possible Clostridium difficile infection. Given the difference in R1 side chains between penicillin and cefazolin, cefazolin use is safe and should be recommended for patients with a penicillin allergy, including those who experience Immunoglobulin E-mediated reactions such as anaphylaxis. Cefazolin should only be avoided in those who experience a history of a severe, life-threatening delayed hypersensitivity reaction manifested as severe cutaneous adverse reactions (Steven-Johnson Syndrome), hepatitis, nephritis, serum sickness, and hemolytic anemia in response to penicillin administration. In addition, >90% of those with a documented penicillin allergy do not have true allergies on skin testing. Increased referral for penicillin allergy testing should be incorporated into routine obstetric care and preoperative assessment to reduce suboptimal antibiotic prophylaxis use. More education is needed among providers surrounding penicillin allergy assessment and cross-reactivity among penicillins and cephalosporins to optimize antibiotic prophylaxis in obstetrics and gynecology.
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Affiliation(s)
- Karley J Dutra
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC.
| | - Gweneth B Lazenby
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC
| | - Oluwatosin Goje
- Department of Subspecialties, Obstetrics and Gynecology Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - David E Soper
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC
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2
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Ribero L, Santía MC, Borchardt K, Zabaneh F, Beck A, Sadhu A, Edwards K, Harrelson M, Pinales-Rodriguez A, Yates EM, Ramirez PT. Surgical site infection prevention bundle in gynecology oncology surgery: a key element in the implementation of an enhanced recovery after surgery (ERAS) program. Int J Gynecol Cancer 2024; 34:1445-1453. [PMID: 38876786 DOI: 10.1136/ijgc-2024-005423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2024] Open
Abstract
Surgical site infection rates are among 5-35% in all gynecologic oncology procedures. Such infections lead to increased patient morbidity, reduction in quality of life, higher likelihood of readmissions, and reinterventions, which contribute directly to mortality and increase in health-related costs. Some of these are potentially preventable by applying evidence-based strategies in the peri-operative patient setting. The objective of this review is to provide recommendations for the individual components that most commonly comprise the surgical site infection prevention bundles that could be implemented in gynecologic oncology procedures. We searched articles from relevant publications with specific topics related to each surgical site infection intervention chosen to be reviewed. Studies on each topic were selected with an emphasis on meta-analyses, systematic reviews, randomized control studies, non-randomized controlled studies, reviews, clinical practice guidelines, and case series. Data synthesis was done through content and thematic analysis to identify key themes in the included studies. This review intends to serve as the most up-to-date frame of evidence-based peri-operative care in our specialty and could serve as the first initiative to introduce an enhanced recovery after surgery (ERAS) program.
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Affiliation(s)
- Lucia Ribero
- Division of Gynecologic Surgery, European Institute of Oncology, Milan, Italy
| | - María Clara Santía
- Department of Obstetrics and Gynecology, Houston Methodist Hospital Neal Cancer Center, Houston, Texas, USA
| | - Kathleen Borchardt
- Department of Obstetrics and Gynecology, Houston Methodist Hospital Neal Cancer Center, Houston, Texas, USA
| | - Firaz Zabaneh
- Department of System Infection Control, Houston Methodist Hospital, Houston, Texas, USA
| | - Amanda Beck
- Department of Pharmacy, Houston Methodist Hospital, Houston, Texas, USA
| | - Archana Sadhu
- Department of Endocrinology, Houston Methodist Hospital, Houston, Texas, USA
| | - Karen Edwards
- Department of Obstetrics and Gynecology, Houston Methodist Hospital Neal Cancer Center, Houston, Texas, USA
| | - Monica Harrelson
- Department of Obstetrics and Gynecology, Houston Methodist Hospital Neal Cancer Center, Houston, Texas, USA
| | - Aimee Pinales-Rodriguez
- Department of Obstetrics and Gynecology, Houston Methodist Hospital Neal Cancer Center, Houston, Texas, USA
| | - Elise Mann Yates
- Department of Obstetrics and Gynecology, Houston Methodist Hospital Neal Cancer Center, Houston, Texas, USA
| | - Pedro T Ramirez
- Department of Obstetrics and Gynecology, Houston Methodist Hospital Neal Cancer Center, Houston, Texas, USA
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3
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Chalif J, Chambers LM, Yao M, Kuznicki M, DeBernardo R, Rose PG, Michener CM, Vargas R. Extended-duration antibiotics are not associated with a reduction in surgical site infection in patients with ovarian cancer undergoing cytoreductive surgery with large bowel resection. Gynecol Oncol 2024; 186:161-169. [PMID: 38691986 DOI: 10.1016/j.ygyno.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/26/2024] [Accepted: 04/05/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVE(S) To evaluate whether extended dosing of antibiotics (ABX) after cytoreductive surgery (CRS) with large bowel resection for advanced ovarian cancer is associated with reduced incidence of surgical site infection (SSI) compared to standard intra-operative dosing and evaluate predictors of SSI. METHODS A retrospective single-institution cohort study was performed in patients with stage III/IV ovarian cancer who underwent CRS from 2009 to 2017. Patients were divided into two cohorts: 1) standard intra-operative dosing ABX and 2) extended post-operative ABX. All ABX dosing was at the surgeon's discretion. The impact of antibiotic duration on SSI and other postoperative outcomes was assessed using univariate and multivariable Cox regression models. RESULTS In total, 277 patients underwent cytoreductive surgery (CRS) with large bowel resection between 2009 and 2017. Forty-nine percent (n = 137) received standard intra-operative ABX and 50.5% (n = 140) received extended post-operative ABX. Rectosigmoid resection was the most common large bowel resection in the standard ABX (89.9%, n = 124) and extended ABX groups (90.0%, n = 126), respectively. No significant differences existed between age, BMI, hereditary predisposition, or medical comorbidities (p > 0.05). No difference was appreciated in the development of superficial incisional SSI between the standard ABX and extended ABX cohorts (10.9% vs. 12.9%, p = 0.62). Of patients who underwent a transverse colectomy, a larger percentage of patients developed a superficial SSI versus no SSI (21% vs. 6%, p = 0.004). CONCLUSION(S) In this retrospective study of patients with advanced ovarian cancer undergoing CRS with LBR, extended post-operative ABX was not associated with reduced SSI, and prolonged administration of antibiotics should be avoided unless clinically indicated.
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Affiliation(s)
- Julia Chalif
- Division of Gynecologic Oncology, James Cancer Hospital and Solove Research Institute, The Ohio State University Medical Center, Columbus, OH 43210, United States of America.
| | - Laura M Chambers
- Division of Gynecologic Oncology, James Cancer Hospital and Solove Research Institute, The Ohio State University Medical Center, Columbus, OH 43210, United States of America
| | - Meng Yao
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH 44195, United States of America
| | - Michelle Kuznicki
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
| | - Robert DeBernardo
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
| | - Peter G Rose
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
| | - Chad M Michener
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
| | - Roberto Vargas
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
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4
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Ejaredar M, Ruzycki SM, Glazer TS, Trudeau P, Jim B, Nelson G, Cameron A. Implementation of a surgical site infection prevention bundle in gynecologic oncology patients: An enhanced recovery after surgery initiative. Gynecol Oncol 2024; 185:173-179. [PMID: 38430815 DOI: 10.1016/j.ygyno.2024.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 02/10/2024] [Accepted: 02/17/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE To evaluate the clinical outcomes pre- and post-implementation of an evidence-informed surgical site infection prevention bundle (SSIPB) in gynecologic oncology patients within an Enhanced Recovery After Surgery (ERAS) care pathway. METHODS Patients undergoing laparotomy for a gynecologic oncology surgery between January-June 2017 (pre-SSIPB) and between January 2018-December 2020 (post-SSIPB) were compared using t-tests and chi-square. Patient characteristics, surgical factors, and ERAS process measures and outcomes were abstracted from the ERAS® Interactive Audit System (EIAS). The primary outcomes were incidence of surgical site infections (SSI) during post-operative hospital admission and at 30-days post-surgery. Secondary outcomes included total postoperative infections, length of stay, and any surgical complications. Multivariate models were used to adjust for potential confounding factors. RESULTS Patient and surgical characteristics were similar in the pre- and post-implementation periods. Evaluation of implementation suggested that preoperative and intraoperative components of the intervention were most consistently used. Infectious complications within 30 days of surgery decreased from 42.1% to 24.4% after implementation of the SSIPB (p < 0.001), including reductions in wound infections (17.0% to 10.8%, p = 0.02), urinary tract infections (UTI) (12.7% to 4.5%, p < 0.001), and intra-abdominal abscesses (5.4% to 2.5%, p = 0.05). These reductions were associated with a decrease in median length of stay from 3 to 2 days (p = 0.001). In multivariate analysis, these SSI reductions remained statistically significant after adjustment for potential confounders. CONCLUSION Implementation of SSIPB was associated with a reduction in SSIs and infectious complications, as well as a shorter length of stay in gynecologic oncology patients.
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Affiliation(s)
- Maede Ejaredar
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shannon M Ruzycki
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tali Sara Glazer
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Pat Trudeau
- Surgery Strategic Clinical Network TM, Alberta Health Services, Edmonton, Alberta, Canada
| | - Brent Jim
- Department of Oncology & Department of Obstetrics and Gynecology, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Gregg Nelson
- Department of Oncology and Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Anna Cameron
- Department of Oncology and Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Natarajan P, Delanerolle G, Dobson L, Xu C, Zeng Y, Yu X, Marston K, Phan T, Choi F, Barzilova V, Powell SG, Wyatt J, Taylor S, Shi JQ, Hapangama DK. Surgical Treatment for Endometrial Cancer, Hysterectomy Performed via Minimally Invasive Routes Compared with Open Surgery: A Systematic Review and Network Meta-Analysis. Cancers (Basel) 2024; 16:1860. [PMID: 38791939 PMCID: PMC11119247 DOI: 10.3390/cancers16101860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/06/2024] [Accepted: 04/27/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Total hysterectomy with bilateral salpingo-oophorectomy via minimally invasive surgery (MIS) has emerged as the standard of care for early-stage endometrial cancer (EC). Prior systematic reviews and meta-analyses have focused on outcomes reported solely from randomised controlled trials (RCTs), overlooking valuable data from non-randomised studies. This inaugural systematic review and network meta-analysis comprehensively compares clinical and oncological outcomes between MIS and open surgery for early-stage EC, incorporating evidence from randomised and non-randomised studies. Methods: This study was prospectively registered on PROSPERO (CRD42020186959). All original research of any experimental design reporting clinical and oncological outcomes of surgical treatment for endometrial cancer was included. Study selection was restricted to English-language peer-reviewed journal articles published 1 January 1995-31 December 2021. A Bayesian network meta-analysis was conducted. Results: A total of 99 studies were included in the network meta-analysis, comprising 181,716 women and 14 outcomes. Compared with open surgery, laparoscopic and robotic-assisted surgery demonstrated reduced blood loss and length of hospital stay but increased operating time. Compared with laparoscopic surgery, robotic-assisted surgery was associated with a significant reduction in ileus (OR = 0.40, 95% CrI: 0.17-0.87) and total intra-operative complications (OR = 0.38, 95% CrI: 0.17-0.75) as well as a higher disease-free survival (OR = 2.45, 95% CrI: 1.04-6.34). Conclusions: For treating early endometrial cancer, minimal-access surgery via robotic-assisted or laparoscopic techniques appears safer and more efficacious than open surgery. Robotic-assisted surgery is associated with fewer complications and favourable oncological outcomes.
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Affiliation(s)
- Purushothaman Natarajan
- Department of Women’s & Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L8 7SS, UK
- Liverpool Women’s Hospital NHS Foundation Trust, Liverpool L8 7SS, UK
| | - Gayathri Delanerolle
- Institute of Applied Health Research, College of Medicine, University of Birmingham, Vincent Drive, Edgbaston B15 2TT, UK
| | - Lucy Dobson
- Department of Women’s & Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L8 7SS, UK
- Liverpool Women’s Hospital NHS Foundation Trust, Liverpool L8 7SS, UK
| | - Cong Xu
- Department of Statistics and Data Science, Southern University of Science and Technology, Shenzhen 518055, China
| | - Yutian Zeng
- Department of Statistics and Data Science, Southern University of Science and Technology, Shenzhen 518055, China
| | - Xuan Yu
- Department of Statistics and Data Science, Southern University of Science and Technology, Shenzhen 518055, China
| | - Kathleen Marston
- Department of Women’s & Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L8 7SS, UK
| | - Thuan Phan
- Department of Women’s & Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L8 7SS, UK
| | - Fiona Choi
- Department of Women’s & Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L8 7SS, UK
- Liverpool Women’s Hospital NHS Foundation Trust, Liverpool L8 7SS, UK
| | - Vanya Barzilova
- Department of Women’s & Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L8 7SS, UK
| | - Simon G. Powell
- Department of Women’s & Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L8 7SS, UK
| | - James Wyatt
- Department of Women’s & Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L8 7SS, UK
| | - Sian Taylor
- Liverpool Women’s Hospital NHS Foundation Trust, Liverpool L8 7SS, UK
| | - Jian Qing Shi
- Department of Statistics and Data Science, Southern University of Science and Technology, Shenzhen 518055, China
- National Center for Applied Mathematics Shenzhen, Shenzhen 518038, China
| | - Dharani K. Hapangama
- Department of Women’s & Children’s Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool L8 7SS, UK
- Liverpool Women’s Hospital NHS Foundation Trust, Liverpool L8 7SS, UK
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6
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Yang R, Wang L, Shui C. A meta-analysis of the risk factors of surgical site infection after hysterectomy for endometrial cancer. Int Wound J 2023; 21:e14420. [PMID: 37830142 PMCID: PMC10825069 DOI: 10.1111/iwj.14420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 09/16/2023] [Indexed: 10/14/2023] Open
Abstract
Surgical Site Infection (SSI) is one of the common postoperative complications after hysterectomy for endometrial cancer (EC). Previous studies have investigated the risk factors for SSI in patients with EC. However, big differences in research results exist, and the correlation coefficients of different research results are quite different. A meta-analysis was conducted to examine the risk factors related to SSI in patients with EC. We searched English databases to collect case-control studies or cohort studies published before July 20, 2023, including PubMed, Web of Science, Embase and ScienceDirect. The risk of bias in the included studies was assessed via Newcastle-Ottawa Scale. The analysis was performed using RevMan 5.4.1 tool. A total of 6 articles (n = 3647) were selected in this meta-analysis. The following risk factors were presented to be significantly correlated with SSI in EC: laparotomy (OR = 2.66, 95% CI [1.57, 4.54]), postoperative blood sugar ≥10 mmol/L (OR = 4.38, 95% CI [2.83, 6.78]), Federation International of Gynaecology and Obstetrics (FIGO) stage-III or IV (OR = 2.27, 95% CI [1.49, 3.46]). The occurrence of SSI is influenced by a variety of factors. Thus, we should pay close attention to high-risk subjects and take crucial targeted interventions to lower the SSI risk after hysterectomy. Owing to the limited quality and quantity of the included studies, more rigorous studies with adequate sample sizes are needed to verify the conclusion.
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Affiliation(s)
- Rong Yang
- Department of Obstetrics and GynecologyThe Central Hospital of Enshi Tujia and Miao Autonomous PrefectureEnshiChina
| | - Lu Wang
- Department of Obstetrics and GynecologyThe Central Hospital of Enshi Tujia and Miao Autonomous PrefectureEnshiChina
| | - ChengYu Shui
- Department of Obstetrics and GynecologyThe Central Hospital of Enshi Tujia and Miao Autonomous PrefectureEnshiChina
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Correa-Paris A, Gorraiz Ochoa V, Hernandez Gutiérrez A, Gilabert Estellés J, Díaz-Feijoo B, Gil-Moreno A. Simple radiologic assessment of visceral obesity and prediction of surgical morbidity in endometrial cancer patients undergoing laparoscopic aortic lymphadenectomy: A reliability and accuracy study. J Obstet Gynaecol Res 2023; 49:988-997. [PMID: 36593218 DOI: 10.1111/jog.15528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 12/05/2022] [Indexed: 01/04/2023]
Abstract
AIM To evaluate the reliability of sagittal abdominal diameter (SAD)-a surrogate of visceral obesity-in magnetic resonance imaging, and its accuracy to predict the surgical morbidity of aortic lymphadenectomy. METHODS We conducted a multicenter reliability (phase 1) and accuracy (phase 2) cohort study in three Spanish referral hospitals. We retrospectively analyzed data from the STELLA-2 randomized controlled trial that included high-risk endometrial cancer patients undergoing minimally invasive surgical staging. Patients were classified into subgroups: conventional versus robotic-assisted laparoscopy, and transperitoneal versus extraperitoneal technique. In the first phase, we measured the agreement of three SAD measurements (at the umbilicus, renal vein, and inferior mesenteric artery) and selected the most reliable one. In phase 2, we evaluated the diagnostic accuracy of SAD to predict surgical morbidity. Surgical morbidity was the main outcome measure, it was defined by a core outcome set including variables related to blood loss, operative time, surgical complications, and para-aortic lymphadenectomy difficulty. RESULTS In phase 1, all measurements showed good inter-rater and intra-rater agreement. Umbilical SAD (u-SAD) was the most reliable one. In phase 2, we included 136 patients. u-SAD had a good diagnostic accuracy to predict surgical morbidity in patients undergoing transperitoneal laparoscopic lymphadenectomy (0.73 in ROC curve). It performed better than body mass index and other anthropometric measurements. We calculated a cut-off point of 246 mm (sensitivity: 0.56, specificity: 0.80). CONCLUSIONS u-SAD is a simple, reliable, and potentially useful measurement to predict surgical morbidity in endometrial cancer patients undergoing minimally invasive surgical staging, especially when facing transperitoneal aortic lymphadenectomy.
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Affiliation(s)
- Alejandro Correa-Paris
- Obstetrics and Gynecology Department, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Verónica Gorraiz Ochoa
- Obstetrics and Gynecology Department, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Juan Gilabert Estellés
- Obstetrics and Gynecology Department, Hospital General de Valencia, Valencia, Spain.,University of Valencia, Valencia, Spain
| | - Berta Díaz-Feijoo
- Obstetrics and Gynecology Department, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antonio Gil-Moreno
- Obstetrics and Gynecology Department, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain.,Biomedical Research Group in Gynecology, Vall d'Hebron Institut de Recerca, Barcelona, Spain
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8
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Swift BE, Maeda A, Bouchard-Fortier G. Adverse postoperative outcomes associated with perioperative blood transfusion in gynecologic oncology surgery. Int J Gynecol Cancer 2023; 33:585-591. [PMID: 36792167 DOI: 10.1136/ijgc-2022-004228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
OBJECTIVE To examine the incidence of perioperative blood transfusion and association with 30 day postoperative outcomes in gynecologic cancer surgery. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify all gynecologic oncology cases from 2013 to 2019. Clinical and surgical characteristics and 30 day postoperative complications were retrieved. The primary outcome was 30 day composite morbidity, based on the occurrence of one or more of the 18 adverse events. Secondary outcomes were 30 day mortality, length of stay in hospital, and composite surgical site infection, defined as superficial, deep, or organ space surgical site infection. The χ2 test and logistic regression analyses were performed to compare the outcomes of patients with and without perioperative blood transfusion. RESULTS There were 62 531 surgical gynecologic oncology cases with an overall transfusion incidence of 9.4%. The transfusion incidence was significantly higher at 22.4% with laparotomy compared with 1.7% with minimally invasive surgery (p<0.0001). On multivariable analysis for laparotomy patients, blood transfusion was predictive of composite morbidity (adjusted odds ratio (OR) 1.65, 95% confidence interval (CI) 1.48 to 1.85) and length of stay in hospital ≥5 days (adjusted OR 9.02, 95% CI 8.21 to 9.92). In advanced ovarian cancer patients (n=3890), the incidence of perioperative blood transfusion was 40.8%. On multivariable analysis, perioperative blood transfusion was the most predictive factor for composite morbidity (adjusted OR 1.67, 95% CI 1.35 to 2.07) and length of stay in hospital ≥7 days (adjusted OR 9.75, 95% CI 7.79 to 12.21). CONCLUSION Perioperative blood transfusion is associated with increased composite morbidity and prolonged length of stay in hospital. Preoperative patient optimization and institutional practices should be reviewed to improve the use of blood bank resources and adherence to restrictive blood transfusion protocols.
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Affiliation(s)
- Brenna E Swift
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
| | - Azusa Maeda
- Strategic Research Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Geneviève Bouchard-Fortier
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada .,Division of Gynecologic Oncology, University Health Network, Toronto, Ontario, Canada
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9
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Felix AS, Nafiu T, Cosgrove CM, Ewing AP, Mpody C. Racial Disparities in Surgical Outcomes Among Women with Endometrial Cancer. Ann Surg Oncol 2022; 29:8338-8344. [PMID: 36138286 PMCID: PMC10316673 DOI: 10.1245/s10434-022-12527-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 08/19/2022] [Indexed: 11/18/2022]
Abstract
PURPOSE Endometrial cancer (EC) is the most common gynecological cancer among women in the United States. Despite well-documented racial/ethnic disparities in EC incidence and mortality rates, limited data exist regarding disparities in hysterectomy surgical outcomes. We evaluated associations of race/ethnicity with postoperative complications, serious adverse events (SAEs), and length of hospital stay among women undergoing EC-related hysterectomy. METHODS Using National Surgical Quality Improvement Program (NSQIP) data, we identified women (≥18 years) undergoing hysterectomy to treat EC between 2014 and 2020. We used multivariable logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for associations of race/ethnicity (white, black, and Latina) with postoperative complications and SAEs. We used Poisson regression with robust standard errors to calculate incidence rate ratios (IRRs) and 95% CIs for the association of race/ethnicity with length of hospital stay. RESULTS Of 22,778 women undergoing EC-related hysterectomy, 3.1% developed postoperative complications. Black (adjusted OR: 1.62; 95% CI 1.05-2.48) and Latina women (adjusted OR: 1.79; 95% CI 1.04-3.09) had higher postoperative complication risks than white women. The overall SAE incidence was 5.0%. Black women (adjusted OR: 1.55, 95% CI 1.13-2.15) had higher SAE risks than white women. Length of hospital stay was significantly longer for black women than white women (IRR: 1.18; 95% CI 1.07-1.30). CONCLUSIONS We observed racial/ethnic disparities in EC-related hysterectomy surgical outcomes in a large, diverse sample of U.S. women between 2014 and 2020. Studies to elucidate the underlying mechanisms of these racial disparities, with a focus on social context remain necessary.
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Affiliation(s)
- Ashley S Felix
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, USA.
| | - Toluwaniose Nafiu
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Casey M Cosgrove
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Aldenise P Ewing
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, USA
| | - Christian Mpody
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, OH, USA
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10
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Combined laparoscopic and open colon surgery rankings fail to accurately rank hospitals by surgical-site infection rate. Infect Control Hosp Epidemiol 2022; 44:624-630. [PMID: 35819176 DOI: 10.1017/ice.2022.153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Objective:
To compare strategies for hospital ranking based on colon surgical-site infection (SSI) rate by combining all colon procedures versus stratifying by surgical approach (ie, laparoscopic vs open).
Design:
Retrospective cohort study.
Methods:
We identified SSIs among Medicare beneficiaries undergoing colon surgery from 2009 through 2013 using previously validated methods. We created a risk prediction model for SSI using age, sex, race, comorbidities, surgical approach (laparoscopy vs open), and concomitant colon and noncolon procedures. Adjusted SSI rates were used to rank hospitals. Subanalyses were performed for common colon procedures and procedure types for which there were both open and laparoscopic procedures. We generated ranks using only open and only laparoscopic procedures, overall and for each subanalysis. Rankings were compared using a Spearman correlation coefficient.
Results:
In total, 694,813 colon procedures were identified among 508,135 Medicare beneficiaries. The overall SSI rate was 7.6%. The laparoscopic approach was associated with lower SSI risk (OR, 0.5; 95% CI, 0.4–0.5), and higher SSI risk was associated with concomitant abdominal surgeries (OR, 1.4; 95% CI, 1.4–1.5) and higher Elixhauser score (OR, 1.1; 95% CI, 1.0–1.1). Hospital rankings for laparascopic procedures were poorly correlated with rankings for open procedures (r = 0.23).
Conclusions:
Hospital rankings based on total colon procedures fail to account for differences in SSI risk from laparoscopic vs open procedures. Stratifying rankings by surgical approach yields a more equitable comparison of surgical performance.
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11
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DeMari JA, Boyles GP, Barrington DA, Audrey Busho BS, Jae Baek BS, Cohn DE, Nagel CI. Less is more: Abdominal closure protocol does not reduce surgical site infection after hysterectomy. Gynecol Oncol 2022; 166:69-75. [PMID: 35525601 DOI: 10.1016/j.ygyno.2022.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/21/2022] [Accepted: 04/22/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To determine rates of surgical site infection (SSI) with and without an abdominal closure protocol for gynecologic oncology patients undergoing abdominal hysterectomy. METHODS Consecutive patients were identified using CPT codes who underwent total abdominal hysterectomy by gynecologic oncologists at a tertiary care center from January 1, 2015 to December 31, 2019, and stratified by use of the abdominal closure protocol. Demographic, perioperative, and pathologic variables were collected. Fisher's exact and Chi squared tests were used for categorical variables, logistic regression and student t-tests for continuous variables. Multiple logistic regression was used to analyze the relationships between these variables, use of the closure protocol, and development of SSI. RESULTS 739 patients were included over the study period (n = 393 pre-implementation, n = 346 post-implementation of the abdominal closure protocol,). Baseline demographics including ASA score, BMI, diabetes, and smoking were similar between these groups (P = 0.14-0.94). The rate of SSI within 30 days was 5.9% (23/393) in the pre-protocol group and 8.1% (28/346) under the abdominal closure protocol (P = 0.25). On univariate analysis, factors associated with SSI were BMI >40, diabetes, bowel resection, ASA score 3 or 4, hypertension, and contaminated wound class (uOR 2.31-4.09). On multivariate analysis BMI >40, diabetes, and bowel resection remained independent risk factors (aOR 2.27-2.99), with the closure protocol not achieving significance (aOR 1.43, 95% CI 0.79-2.59). There were no potentially high-risk sub-groups in whom the closing protocol showed benefit. CONCLUSION The abdominal closure protocol in isolation did not decrease SSI in those undergoing TAH by a gynecologic oncologist.
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Affiliation(s)
- Joseph A DeMari
- Division of Gynecologic Oncology, Wake Forest School of Medicine, Winston Salem, USA.
| | - Glenn P Boyles
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, USA
| | - David A Barrington
- Division of Gynecologic Oncology, The Ohio State University, Columbus, USA
| | | | - B S Jae Baek
- College of Medicine, The Ohio State University, Columbus, USA
| | - David E Cohn
- Division of Gynecologic Oncology, The Ohio State University, Columbus, USA
| | - Christa I Nagel
- Division of Gynecologic Oncology, The Ohio State University, Columbus, USA
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12
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Kelly MG, Berry LK, Burnett BA, Lentz SS. Tertiary Wound Closure for High-Risk Patients Undergoing Gynecologic Abdominal Surgery. J Gynecol Surg 2022. [DOI: 10.1089/gyn.2021.0063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Michael G. Kelly
- Section of Gynecologic Oncology, Department of Obstetrics and Gynecology, Wake–Forest University School of Medicine, Winston–Salem, North Carolina, USA
| | - Laurel K. Berry
- Section of Gynecologic Oncology, Department of Obstetrics and Gynecology, Wake–Forest University School of Medicine, Winston–Salem, North Carolina, USA
| | - Brian A. Burnett
- Section of Gynecologic Oncology, Department of Obstetrics and Gynecology, Wake–Forest University School of Medicine, Winston–Salem, North Carolina, USA
| | - Samuel S. Lentz
- Section of Gynecologic Oncology, Department of Obstetrics and Gynecology, Wake–Forest University School of Medicine, Winston–Salem, North Carolina, USA
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13
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Edmiston CE, Bond-Smith G, Spencer M, Chitnis AS, Holy CE, Po-Han Chen B, Leaper DJ. Assessment of risk and economic burden of surgical site infection (SSI) posthysterectomy using a U.S. longitudinal database. Surgery 2021; 171:1320-1330. [PMID: 34973811 DOI: 10.1016/j.surg.2021.11.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 11/17/2021] [Accepted: 11/29/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surgical site infection posthysterectomy has significant impact on patient morbidity, mortality, and health care costs. This study evaluates incidence, risk factors, and total payer costs of surgical site infection after hysterectomy in commercial, Medicare, and Medicaid populations using a nationwide claims database. METHODS IBM MarketScan databases identified women having hysterectomy between 2014 and 2018. Deep-incisional/organ space (DI/OS) and superficial infections were identified over 6 months postoperatively with risk factors and direct infection-associated payments by insurance type over a 24-month postoperative period. RESULTS Analysis identified 141,869 women; 7.8% Medicaid, 5.8% Medicare, and 3.9% commercially insured women developed deep-incisional/organ space surgical site infection, whereas 3.9% Medicaid, 3.2% Medicare, and 2.1% commercially insured women developed superficial infection within 6 months of index procedure. Deep-incisional/organ space risk factors were open approach (hazard ratio, 1.6; 95% confidence interval, 1.5-1.8) and payer type (Medicaid versus commercial [hazard ratio, 1.4; 95% confidence interval, 1.3-1.5]); superficial risk factors were payer type (Medicaid versus commercial [hazard ratio, 1.4; 95% confidence interval, 1.3-1.6]) and solid tumor without metastasis (hazard ratio, 1.4; 95% confidence interval, 1.3-1.6). Highest payments occurred with Medicare ($44,436, 95% confidence interval: $33,967-$56,422) followed by commercial ($27,140, 95% confidence interval: $25,990-$28,317) and Medicaid patients ($17,265, 95% confidence interval: $15,247-$19,426) for deep-incisional/organ space infection at 24-month posthysterectomy. CONCLUSIONS Real-world cost of managing superficial, deep-incisional/organ space infection after hysterectomy was significantly higher than previously reported. Surgical approach, payer type, and comorbid risk factors contributed to increased risk of infection and economic burden. Medicaid patients experienced the highest risk of infection, followed by Medicare patients. The study suggests adoption of a robust evidence-based surgical care bundle to mitigate risk of surgical site infection and economic burden is warranted.
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Affiliation(s)
| | | | | | - Abhishek S Chitnis
- Medical Device Epidemiology, Real-World Data Sciences, Johnson & Johnson, New Brunswick, NJ
| | - Chantal E Holy
- Medical Device Epidemiology, Real-World Data Sciences, Johnson & Johnson, New Brunswick, NJ
| | | | - David J Leaper
- University of Newcastle and Emeritus Professor of Clinical Sciences, University of Huddersfield, UK
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14
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Evaluation of the costing methodology of published studies estimating costs of surgical site infections: A systematic review. Infect Control Hosp Epidemiol 2021; 43:898-914. [PMID: 34551830 DOI: 10.1017/ice.2021.381] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Surgical site infections (SSIs) are associated with increased length of hospitalization and costs. Epidemiologists and infection control practitioners, who are in charge of implementing infection control measures, have to assess the quality and relevance of the published SSI cost estimates before using them to support their decisions. In this review, we aimed to determine the distribution and trend of analytical methodologies used to estimate cost of SSIs, to evaluate the quality of costing methods and the transparency of cost estimates, and to assess whether researchers were more inclined to use transferable studies. METHODS We searched MEDLINE to identify published studies that estimated costs of SSIs from 2007 to March 2021, determined the analytical methodologies, and evaluated transferability of studies based on 2 evaluation axes. We compared the number of citations by transferability axes. RESULTS We included 70 studies in our review. Matching and regression analysis represented 83% of analytical methodologies used without change over time. Most studies adopted a hospital perspective, included inpatient costs, and excluded postdischarge costs (borne by patients, caregivers, and community health services). Few studies had high transferability. Studies with high transferability levels were more likely to be cited. CONCLUSIONS Most of the studies used methodologies that control for confounding factors to minimize bias. After the article by Fukuda et al, there was no significant improvement in the transferability of published studies; however, transferable studies became more likely to be cited, indicating increased awareness about fundamentals in costing methodologies.
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15
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Shi L, Gu Q, Zhang F, Li D, Ye W, Zhong Y, Shi X. Predictive factors of surgical site infection after hysterectomy for endometrial carcinoma: a retrospective analysis. BMC Surg 2021; 21:292. [PMID: 34126988 PMCID: PMC8201671 DOI: 10.1186/s12893-021-01264-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 05/23/2021] [Indexed: 12/17/2022] Open
Abstract
Background Surgical site infection (SSI) is a common postoperative complication. We aimed to analyze the potential risk factors of SSI in patients with endometrial carcinoma. Methods Patients with endometrial carcinoma who underwent surgery treatment in our hospital from Sept 1, 2018 to August 31, 2020 were included. We retrospectively compared the characteristics of SSI and no SSI patients, and logistic regression analyses were performed to identify the risk factors of SSI in patients with endometrial carcinoma. Results A total of 318 postoperative patients with endometrial carcinoma were included. The incidence of SSI in patients with endometrial carcinoma was 14.47 %. There were significant differences on the FIGO stage, type of surgery, durations of drainage, postoperative serum albumin and postoperative blood sugar (all p < 0.05), and no significant differences on the age, BMI, hypertension, diabetes, hyperlipidemia, estimated blood loss, length of hospital stay were found (all p > 0.05). FIGO stage IV (HR3.405, 95 %CI 2.132–5.625), open surgery (HR2.692, 95 %CI 1.178–3.454), durations of drainage ≥ 7 d (HR2.414,95 %CI 1.125–2.392), postoperative serum albumin < 30 g/L (HR1.912,95 %CI 1.263–2.903), postoperative blood sugar ≥ 10 mmol/L (HR1.774,95 %CI 1.102–2.534) were the independent risk factors of SSI in patients with endometrial carcinoma (all p < 0.05). Conclusions Measures including reasonable control of serum albumin and blood glucose levels, minimally invasive surgery as much as possible, timely assessment of drainage and early removal of the tube may be beneficial to reduce the postoperative SSI in in patients with endometrial carcinoma.
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Affiliation(s)
- Lijuan Shi
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Qiao Gu
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Fenghua Zhang
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Daoyun Li
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Wenfeng Ye
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Yan Zhong
- Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Xiu Shi
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Soochow University, No. 188 Shizi Road, Suzhou, Jiangsu, China.
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16
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Idelson C, Uecker J, Garcia JA, Kohli S, Handing G, Sriramprasad V, Yong K, Rylander C. Design and Performance Testing of a Novel In Vivo Laparoscope Lens Cleaning Device. J Med Device 2021. [DOI: 10.1115/1.4050955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Abstract
A common tool for diagnosis and treatment of gastrointestinal, gynecologic, and other anatomical pathologies is a form of minimally invasive surgery known as laparoscopy. Roughly 4 × 106 laparoscopic surgeries are performed in the U.S. every year, with an estimated 15 × 106 globally. During surgeries, lens clarity often becomes impaired via (1) condensation or (2) smearing of bodily fluids and tissues. The current gold standard solution requires scope removal from the body for cleaning, offering opportunity for decreased surgical safety and efficiency, while simultaneously generating mounting frustration for the operating room team. A novel lens cleaning device was designed and developed to clean a laparoscope lens in vivo during surgery. Benchtop experiments in a warm body simulated environment allowed quantification of lens cleaning efficacy for several lens contaminants. Image analysis techniques detected the differences between original (clean), postdebris, and postcleaning images. Mechanical testing was also executed to determine safety levels regarding potential misuse scenarios. Compared to gold standard device technologies, the novel lens cleaning device prototype showed strong performance and ability to clear a laparoscope lens of debris while mitigating the need for scope removal from the simulated surgical cavity. Mechanical testing results also suggest the design also holds inherently strong safety performance. Both objective metrics and subjective observation suggests the novel design holds promise to improve safety and efficiency during laparoscopic surgery.
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Affiliation(s)
- Christopher Idelson
- ClearCam Inc., Austin, TX 78744; Department of Mechanical Engineering, The University of Texas at Austin, Austin, TX 78712
| | - John Uecker
- ClearCam Inc., Austin, TX 78744; Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX 78712
| | - James A. Garcia
- Department of Mechanical Engineering, The University of Texas at Austin, Austin, TX 78712
| | - Sunjna Kohli
- Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX 78712
| | - Greta Handing
- Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX 78712
| | - Vishrudh Sriramprasad
- Department of Mechanical Engineering, The University of Texas at Austin, Austin, TX 78712
| | - Kirstie Yong
- Department of Mechanical Engineering, The University of Texas at Austin, Austin, TX 78712
| | - Christopher Rylander
- ClearCam Inc., Austin, TX 78744; Department of Mechanical Engineering, The University of Texas at Austin, Austin, TX 78712; Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX 78712
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17
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Caroff DA, Wang R, Zhang Z, Wolf R, Septimus E, Harris AD, Jackson SS, Poland RE, Hickok J, Huang SS, Platt R. The Limited Utility of Ranking Hospitals Based on Their Colon Surgery Infection Rates. Clin Infect Dis 2021; 72:90-98. [PMID: 31918439 PMCID: PMC7823072 DOI: 10.1093/cid/ciaa012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 01/14/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services (CMS) use colon surgical site infection (SSI) rates to rank hospitals and apply financial penalties. The CMS' risk-adjustment model omits potentially impactful variables that might disadvantage hospitals with complex surgical populations. METHODS We analyzed adult patients who underwent colon surgery within facilities associated with HCA Healthcare from 2014 to 2016. SSIs were identified from National Health Safety Network (NHSN) reporting. We trained and validated 3 SSI prediction models, using (1) current CMS model variables, including hospital-specific random effects (HCA-adapted CMS model); (2) demographics and claims-based comorbidities (expanded-claims model); and (3) demographics, claims-based comorbidities, and NHSN variables (claims-plus-electronic health record [EHR] model). Discrimination, calibration, and resulting rankings were compared among all models and the current CMS model with published coefficient values. RESULTS We identified 39 468 colon surgeries in 149 hospitals, resulting in 1216 (3.1%) SSIs. Compared to the HCA-adapted CMS model, the expanded-claims model had similar performance (c-statistic, 0.65 vs 0.67, respectively), while the claims-plus-EHR model was more accurate (c-statistic, 0.70; 95% confidence interval, .67-.73; P = .004). The sampling variation, due to the low surgical volume and small number of infections, contributed 74% of the total variation in observed SSI rates between hospitals. When CMS model rankings were compared to those from the expanded-claims and claims-plus-EHR models, 18 (15%) and 26 (22%) hospitals changed quartiles, respectively, and 10 (8.3%) and 12 (10%) hospitals changed into or out of the lowest-performing quartile, respectively. CONCLUSIONS An expanded set of variables improved colon SSI risk predictions and quartile assignments, but low procedure volumes and SSI events remain a barrier to effectively comparing hospitals.
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Affiliation(s)
- Daniel A Caroff
- Department of Population Medicine, Harvard Medical School and the Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Rui Wang
- Department of Population Medicine, Harvard Medical School and the Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Zilu Zhang
- Department of Population Medicine, Harvard Medical School and the Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Robert Wolf
- Department of Population Medicine, Harvard Medical School and the Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Ed Septimus
- Department of Population Medicine, Harvard Medical School and the Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Anthony D Harris
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sarah S Jackson
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Russell E Poland
- Department of Population Medicine, Harvard Medical School and the Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA.,HCA Healthcare, Nashville, Tennessee, USA
| | | | - Susan S Huang
- Department of Population Medicine, Harvard Medical School and the Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA.,Division of Infectious Diseases and the Health Policy Research Institute, University of California Irvine School of Medicine, Irvine, California, USA
| | - Richard Platt
- Department of Population Medicine, Harvard Medical School and the Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
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18
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Prophylactic Negative Pressure Wound Therapy After Laparotomy for Gynecologic Surgery: A Randomized Controlled Trial. Obstet Gynecol 2021; 137:334-341. [PMID: 33416292 DOI: 10.1097/aog.0000000000004243] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 11/12/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To estimate the effectiveness of prophylactic negative pressure wound therapy in patients undergoing laparotomy for gynecologic surgery. METHODS We conducted a randomized controlled trial. Eligible, consenting patients, regardless of body mass index (BMI), who were undergoing laparotomy for presumed gynecologic malignancy were randomly allocated to standard gauze or negative pressure wound therapy. Patients with BMIs of 40 or greater and benign disease also were eligible. Randomization, stratified by BMI, occurred after skin closure. The primary outcome was wound complication within 30 (±5) days of surgery. A sample size of 343 per group (N=686) was planned. RESULTS From March 1, 2016, to August 20, 2019, we identified 663 potential patients; 289 were randomized to negative pressure wound therapy (254 evaluable participants) and 294 to standard gauze (251 evaluable participants), for a total of 505 evaluable patients. The median age of the entire cohort was 61 years (range 20-87). Four hundred ninety-five patients (98%) underwent laparotomy for malignancy. The trial was eventually stopped for futility after an interim analysis of 444 patients. The rate of wound complications was 17.3% in the negative pressure wound therapy (NPWT) group and 16.3% in the gauze group, absolute risk difference 1% (90% CI -4.5 to 6.5%; P=.77). Adjusted odds ratio controlling for estimated blood loss and diabetes was 0.99 (90% CI 0.62-1.60). Skin blistering occurred in 33 patients (13%) in the NPWT group and in three patients (1.2%) in the gauze group (P<.001). CONCLUSION Negative pressure wound therapy after laparotomy for gynecologic surgery did not lower the wound complication rate but did increase skin blistering. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, NCT02682316. FUNDING SOURCE The protocol was supported in part by KCI/Acelity.
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19
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Tsuzuki Y, Hirata T, Tsuzuki S, Wada S, Tamakoshi A. Risk factors of vaginal cuff infection in women undergoing laparoscopic hysterectomy for benign gynecological diseases. J Obstet Gynaecol Res 2021; 47:1502-1509. [PMID: 33590565 DOI: 10.1111/jog.14632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 11/17/2020] [Accepted: 12/12/2020] [Indexed: 11/29/2022]
Abstract
AIM This study aimed to identify the risk factors for vaginal cuff infection after laparoscopic hysterectomy for benign gynecological diseases. METHODS We conducted a retrospective cohort study among 1559 Japanese women who underwent total laparoscopic hysterectomy (TLH) for benign indications between 2014 and 2018 at Teine Keijinkai Hospital in Sapporo, Japan. All patients received preoperative antibiotics based on appropriate timing, choice, and weight-based dosing. We assessed the risk factors of vaginal cuff infection after TLH, including demographic and clinical variables, and patient- and surgery-related factors, using univariable and multivariable logistic regression analyses. RESULTS Among all the patients who underwent TLH, 71 cases of vaginal cuff infections (4.6%) were recorded. Univariate analyses showed that current smoking, pathological result of adenomyosis, use of Seprafilm as an antiadhesive material, white blood cell counts on postoperative day (POD) 2, C-reactive protein (CRP) level on POD2 and postoperative vaginal cuff hematoma were significantly associated with an increased risk of vaginal cuff infection. In multivariate analysis, current smoking, use of seprafilm, CRP level on POD2 and vaginal cuff hematoma were significantly associated with an increased risk of vaginal cuff infection. CONCLUSION Current smoking, use of seprafilm, CRP level on POD2 and vaginal cuff hematoma were identified as significant risk factors of vaginal cuff infection in the 30 days after surgery in Japanese women who underwent TLH for benign indications.
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Affiliation(s)
- Yoko Tsuzuki
- Department of Obstetrics and Gynecology, Teine Keijinkai Hospital, Sapporo city, Japan.,Department of Public Health, Hokkaido University Faculty and Graduate School of Medicine, Sapporo city, Japan
| | - Takumi Hirata
- Department of Public Health, Hokkaido University Faculty and Graduate School of Medicine, Sapporo city, Japan
| | - Shinya Tsuzuki
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Shinichiro Wada
- Department of Obstetrics and Gynecology, Teine Keijinkai Hospital, Sapporo city, Japan
| | - Akiko Tamakoshi
- Department of Public Health, Hokkaido University Faculty and Graduate School of Medicine, Sapporo city, Japan
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20
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Intraoperative subcutaneous culture as a predictor of surgical site infection in open gynecological surgery. PLoS One 2021; 16:e0244551. [PMID: 33434238 PMCID: PMC7802959 DOI: 10.1371/journal.pone.0244551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 12/13/2020] [Indexed: 11/19/2022] Open
Abstract
Purpose To analyze the relationship between intraoperative cultures and the development of surgical site infection (SSI) in women undergoing laparotomy for gynecological surgery. Methods Prospective observational cohort study. Over a six-year period, women who underwent elective laparotomy at our hospital were included. Patients’ demographics, underlying co-morbidities, surgical variables, type and etiology of postoperative surgical site infections were collected. Skin and subcutaneous samples were taken just prior to skin closure and processed for microbiological analysis. Univariate and multivariate analyses (logistic regression model) were conducted to explore the association of the studied variables with SSIs. Results 284 patients were included in our study, of which 20 (7%) developed surgical site infection, including 11 (55%) superficial and nine (45%) organ-space. At univariate analysis, length of surgery, colon resection, transfusion and positive intraoperative culture were associated with surgical site infection occurrence. Skin and subcutaneous cultures were positive in 25 (8.8%) and 20 (7%) patients, respectively. SSI occurred in 35% of women with positive subcutaneous culture and in 20% of those with positive skin cultures. Using multivariate analysis, the only independent factor associated with surgical site infection was a positive subcutaneous culture (OR 10.4; 95% CI 3.5–30.4; P<0.001). Conclusion Intraoperative subcutaneous cultures before skin closure may help early prediction of surgical site infection in open gynecological procedures.
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21
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LA Russa M, Liakou C, Burbos N. Ultra-minimally invasive approaches for endometrial cancer treatment: review of the literature. Minerva Med 2020; 112:31-46. [PMID: 33205639 DOI: 10.23736/s0026-4806.20.07073-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION We conducted a systematic review to evaluate the outcomes and role of ultra-minimally invasive surgical approaches for treatment of women diagnosed with endometrial cancer. Although, there is no agreed definition of the term "ultraminimal," we considered the hysteroscopic surgery, single-port surgery, mini/microlaparoscopy and percutaneous laparoscopy as surgical approaches that would best fit this description. EVIDENCE ACQUISITION The current systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Guidelines. We performed a literature search using MEDLINE (PubMed), EMBASE and Cochrane Library databases for English-language studies published before August 1, 2020. We used the following keywords including "endometrial cancer," "endometrial malignancy," "fertility-sparing or preserving," "hysteroscopy," "hysteroscopic resection," "dilatation and curettage," "ultra-minimally invasive surgery," "progestin therapy," "hormone therapy," "single port," "single-site," "minilaparoscopy," "microlaparoscopy," "percutaneous" and "3 mm laparoscopy." EVIDENCE SYNTHESIS A total of 21 studies, reporting on 229 patients were included. 219 (95.6%) of the patients were premenopausal. Among premenopausal women, complete disease response was reported in 186 (84.9%) patients. The complete response rate was 77.1% in patients who underwent focal or extensive endometrial resection, 90.9% in patients who had the two-step approach and 88.9% in the group of patients treated with the three-step technique. Among 98 women who wished and attempted to conceive, 65 (66.3%) women became pregnant. Recurrent disease was diagnosed in 26 of 219 (11.9%) patients. No surgical complications were reported. In 10 postmenopausal patients that underwent hysteroscopic resection, no recurrences were detected after 5 years of follow-up. We identified 11 studies that reported on the use single-port laparoscopic surgery and included a total of 447 patients. The rate of intraoperative and postoperative complications was 2.6% and 5.2%, respectively. The majority of the studies did not report on the duration of follow-up or oncological outcomes. Ten studies, including 296 patients, investigated the role of single-port robotic-assisted laparoscopy. The overall rate of intraoperative and postoperative complications was 1.0% and 7.1%, respectively. Two studies, including 38 patients, reported on the role of minilaparoscopy. None of these cases required conversion to laparotomy. Data on overall survival in the cohort of patients that underwent minilaparoscopy were not reported. We found only one publication reporting on the use of percutaneous laparoscopy. This prospective study included 30 patients. No complication was reported, and with a median follow-up time of 14 months (range 12-36) no recurrences were diagnosed. CONCLUSIONS Several ultra-minimally invasive surgical techniques have been developed and implemented in selected patients with endometrial cancer. The results of this review support the feasibility and perioperative safety of these approaches, while long-term outcomes are not adequately studied. However, further work is required in standardization of the techniques, in determining the learning curve of the operator and establishing their oncological safety.
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Affiliation(s)
- Mariaclelia LA Russa
- Department of Gynecological Oncology, Norfolk and Norwich University Hospital, Norwich, UK -
| | - Chrysoula Liakou
- Department of Gynecological Oncology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Nikolaos Burbos
- Department of Gynecological Oncology, Norfolk and Norwich University Hospital, Norwich, UK
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Poliquin V, Singh PK, Leylek M, Dean E, Liu M, Altman AD. The Risk of Postoperative Infectious Complications Following Massive Intraoperative Blood Loss During Gynaecologic Laparotomy: Retrospective Cohort Study. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 43:19-25. [PMID: 33153939 DOI: 10.1016/j.jogc.2020.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 07/25/2020] [Accepted: 07/27/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To determine whether massive intraoperative blood loss (MIBL) was independently associated with postoperative infectious complications after gynaecologic laparotomy. METHODS We conducted a retrospective cohort study of patients undergoing gynaecologic laparotomy who were exposed or not exposed to MIBL. The outcome of interest was composite postoperative febrile morbidity. Multiple logistic regression was used to determine the association between exposure and outcome while controlling for measured covariates. RESULTS The primary outcome was identified to have occurred in 48% (144 of 298) of surgeries with MIBL compared with 12% (51 of 413) of surgeries without MIBL (P < 0.0001). MIBL was found to be strongly and independently associated with primary outcome (adjusted odds ratio 7.04; 95% confidence interval 4.62-10.74; P < 0.0001) after adjusting for age, body mass index, diabetes, immunosuppression, type of procedure, incision type, drains left in situ, and bowel complications. CONCLUSION MIBL is strongly and independently associated with postoperative febrile morbidity after gynaecologic laparotomy.
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Affiliation(s)
- Vanessa Poliquin
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Manitoba, Winnipeg, MB
| | - Prabjot K Singh
- Max Rady College of Medicine, University of Manitoba, Winnipeg, MB
| | - Melike Leylek
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Manitoba, Winnipeg, MB
| | - Erin Dean
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Manitoba, Winnipeg, MB
| | - Michelle Liu
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Manitoba, Winnipeg, MB
| | - Alon D Altman
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Manitoba, Winnipeg, MB.
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Chambers LM, Morton M, Lampert E, Yao M, Debernardo R, Rose PG, Vargas R. Use of prophylactic closed incision negative pressure therapy is associated with reduced surgical site infections in gynecologic oncology patients undergoing laparotomy. Am J Obstet Gynecol 2020; 223:731.e1-731.e9. [PMID: 32417358 DOI: 10.1016/j.ajog.2020.05.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/25/2020] [Accepted: 05/07/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Surgical site infection after surgery for gynecologic cancer increases morbidity. Prophylactic closed incision negative pressure therapy has shown promise in reducing infectious wound complications across many surgical disciplines. OBJECTIVE This study aimed to determine whether closed incision negative pressure therapy is associated with reduced surgical site infections in gynecologic oncology patients undergoing laparotomy compared with standard dressings. STUDY DESIGN This was a retrospective case-control study of patients undergoing laparotomy for known or suspected gynecologic cancer from Jan. 1, 2017, to Feb. 1, 2020. Patients were matched in a 1:3 ratio (closed incision negative pressure therapy to standard dressing) by body mass index, age, diabetes, bowel surgery, smoking, and steroid use. Surgical site infection was defined according to the Centers for Disease Control and Prevention. Multivariable logistic regression using backward selection was performed. RESULTS Of the 1223 eligible patients undergoing laparotomy, 64 (5.2%) received closed incision negative pressure therapy dressings and were matched to 192 (15.7%) controls. There were no differences in medical comorbidities (P>.05), site or stage of malignancy (P>.05), duration of surgery (P=.82), or surgical procedures (P>.05). Use of closed incision negative pressure therapy was associated with reduction in all adverse wound outcomes (20.3% vs 40.1%; P<.001). In particular, closed incision negative pressure therapy was associated with a significant reduction in both superficial incisional surgical site infections (9.4% vs 29.7%; P<.001) and deep incisional surgical site infections (0.0% vs 6.8%; P=.04). In multivariable analysis, use of closed incision negative pressure therapy was associated with significant reduction in the incidence of superficial incisional infections alone (odds ratio, 0.29; 95% confidence interval, 0.12-0.73; P=.008) and both superficial and deep incisional infections (odds ratio, 0.29; 95% confidence interval, 0.12-0.71; P=.007). CONCLUSION Use of prophylactic closed incision negative pressure therapy after laparotomy in gynecologic oncology patients was found to be associated with reduced superficial incisional and deep incisional infections compared with standard dressings. Furthermore, closed incision negative pressure therapy was associated with reduction in all other adverse wound outcomes. Closed incision negative pressure therapy may be considered for surgical site infection prevention in high-risk gynecologic oncology patients undergoing laparotomy.
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Affiliation(s)
- Laura Moulton Chambers
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH.
| | - Molly Morton
- Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Erika Lampert
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH
| | - Meng Yao
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Robert Debernardo
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Peter G Rose
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH
| | - Roberto Vargas
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH
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Kuznicki M, Mallen A, McClung EC, Robertson SE, Todd S, Boulware D, Martin S, Quilitz R, Vargas RJ, Apte SM. Dual antibiotic prevention bundle is associated with decreased surgical site infections. Int J Gynecol Cancer 2020; 30:1411-1417. [PMID: 32727930 DOI: 10.1136/ijgc-2020-001515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 07/06/2020] [Accepted: 07/08/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Gynecologic oncology surgery is associated with a wide variation in surgical site infection risk. The optimal method for infection prevention in this heterogeneous population remains uncertain. STUDY DESIGN A retrospective cohort study was performed to compare surgical site infection rates for patients undergoing hysterectomy over a 1-year period surrounding the implementation of an institutional infection prevention bundle. The bundle comprised pre-operative, intra-operative, and post-operative interventions including a dual-agent antibiotic surgical prophylaxis with cefazolin and metronidazole. Cohorts consisted of patients undergoing surgery during the 6 months prior to this intervention (pre-bundle) versus those undergoing surgery during the 6 months following the intervention (post-bundle). Secondary outcomes included length of stay, readmission rates, compliance measures, and infection microbiology. Data were compared with pre-specified one-sided exact test, Chi-square test, Fisher's exact test, or Kruskal-Wallis test as appropriate. RESULTS A total of 358 patients were included (178 PRE, 180 POST). Median age was 58 (range 23-90) years. The post-bundle cohort had a 58% reduction in surgical site infection rate, 3.3% POST vs 7.9% PRE (-4.5%, 95% CI -9.3% to -0.2%, p=0.049) as well as reductions in organ space infection, 0.6% POST vs 4.5% PRE (-3.9%, 95% CI -7.2% to -0.7%, p=0.019), and readmission rates, 2.2% POST vs 6.7% PRE (-4.5%, 95% CI -8.7% to -0.2%, p=0.04). Gram-positive, Gram-negative, and anaerobic bacteria were all prevalent in surgical site infection cultures. There were no monomicrobial infections in post-cohort cultures (0% POST vs 58% PRE, p=0.04). No infections contained methicillin-resistant Staphylococcus aureus. CONCLUSION Implementation of a dual antibiotic infection prevention bundle was associated with a 58% reduction in surgical site infection rate after hysterectomy in a surgically diverse gynecologic oncology practice.
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Affiliation(s)
- Michelle Kuznicki
- Gynecologic Oncology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Adrianne Mallen
- Gynecologic Oncology, University of South Florida, Tampa, Florida, USA.,Gynecologic Oncology, H Lee Moffitt Cancer Center and Research Center Inc, Tampa, Florida, USA
| | - Emily Clair McClung
- Gynecologic Oncology, University of Arizona Arizona Health Sciences Center, Tucson, Arizona, USA
| | - Sharon E Robertson
- Gynecologic Oncology, Indiana University School of Medicine, Indianapolis, Indiana, USA.,Gynecologic Oncology, Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Indiana, USA
| | - Sarah Todd
- Gynecologic Oncology, University of Louisville, Louisville, Kentucky, USA
| | - David Boulware
- Infection Prevention, H Lee Moffitt Cancer Center and Research Center Inc, Tampa, Florida, USA
| | - Stacy Martin
- Infection Prevention, H Lee Moffitt Cancer Center and Research Center Inc, Tampa, Florida, USA
| | - Rod Quilitz
- Pharmacy, H Lee Moffitt Cancer Center and Research Center Inc, Tampa, Florida, United States
| | - Roberto J Vargas
- Gynecologic Oncology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Sachin M Apte
- Gynecologic Oncology, H Lee Moffitt Cancer Center and Research Center Inc, Tampa, Florida, USA
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Fenny AP, Asante FA, Otieku E, Bediako-Bowan A, Enemark U. Attributable cost and extra length of stay of surgical site infection at a Ghanaian teaching hospital. Infect Prev Pract 2020; 2:100045. [PMID: 34368695 PMCID: PMC8336154 DOI: 10.1016/j.infpip.2020.100045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 02/09/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Limited information is available on the financial impact of healthcare associated infections in Sub-Saharan Africa. A prospective case-control study was undertaken at Korle-Bu Teaching Hospital, Ghana, to calculate the cost of surgical site infections (SSI). METHODS We studied 446 adults undergoing surgery from the surgical department. In all, 40 patients with SSI and 40 control patients without SSI were matched by type of surgery, wound class, ASA, sex and age. The direct and indirect costs to patients were obtained from patients and their carers, daily. The cost of drugs was confirmed with the pharmacy at the department. RESULTS The prevalence rate for SSI was 11% of the total 446 cases sampled between June and August 2017. On average patients with SSI who undertook hernia surgery paid approximately US$ 392 more than the matched controls without SSI. The least difference was recorded amongst patients who had thyroid surgery, a difference of US$ 42. The results show that for all surgical procedures, SSI patients report excess length of stay. The additional days range from 1 day for limb amputation, to 16 days for rectal surgery. CONCLUSIONS In this study, patients with SSI experienced significant prolongation of hospitalisation and increased use of health care costs. In many cases, the indirect costs were much higher than direct costs. These findings support the need to implement preventative interventions for patients hospitalised for various surgical procedures at the Korle Bu Teaching Hospital.
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Kogan L, Matanes E, Wissing M, Mitric C, How J, Amajoud Z, Abitbol J, Yasmeen A, López-Ozuna V, Eisenberg N, Lau S, Salvador S, Gotlieb WH. The added value of sentinel node mapping in endometrial cancer. Gynecol Oncol 2020; 158:84-91. [PMID: 32349874 DOI: 10.1016/j.ygyno.2020.04.687] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 04/14/2020] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To evaluate long-term oncological outcomes and the added value of sentinel lymph node sampling (SLN) compared to pelvic lymph node dissection (LND) in patients with endometrial cancer (EC). METHODS During the evaluation phase of SLN for EC, we performed LND and SLN and retrospectively compared the oncologic outcome with the immediate non-overlapping historical era during which patients underwent LND. RESULTS From 2007 to 2010, 193 patients underwent LND and from December 2010 to 2014, 250 patients had SLN mapping with completion LND. Both groups had similar clinical characteristics. During a median follow-up period of 6.9 years, addition of SLN was associated with more favorable oncological outcomes compared to LND with 6-year overall survival (OS) of 90% compared to 81% (p = 0.009), and progression free survival (PFS) of 85% compared to 75% (p = 0.01) respectively. SLN was associated with improved OS (HR 0.5, 95% CI 0.3-0.8, p = 0.004), and PFS (HR 0.6, 95% CI 0.4-0.9, p = 0.03) in a multivariable analysis, adjusted for age, ASA score, stage, grade, non-endometrioid histology, and LVSI. Patients who were staged with SLN were less likely to have a recurrence in the pelvis or lymph node basins compared to patients who underwent LND only (6-year recurrence-free survival 95% vs 90%, p = 0.04). CONCLUSION Addition of SLN to LND was ultimately associated with improved clinical outcomes compared to LND alone in patients with endometrial cancer undergoing surgical staging, suggesting that the data provided by the analysis of the SLN added relevant clinical information, and improved the decision on adjuvant therapy.
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Affiliation(s)
- Liron Kogan
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada; Segal Cancer Center, Lady Davis Institute of Medical Research, McGill University, Montreal, Quebec, Canada
| | - Emad Matanes
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada; Segal Cancer Center, Lady Davis Institute of Medical Research, McGill University, Montreal, Quebec, Canada
| | - Michel Wissing
- Division of Cancer Epidemiology, Department of Oncology, McGill University, Montreal, QC, Canada
| | - Cristina Mitric
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Jeffrey How
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Zainab Amajoud
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Jeremie Abitbol
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Amber Yasmeen
- Segal Cancer Center, Lady Davis Institute of Medical Research, McGill University, Montreal, Quebec, Canada
| | - Vanessa López-Ozuna
- Segal Cancer Center, Lady Davis Institute of Medical Research, McGill University, Montreal, Quebec, Canada
| | - Neta Eisenberg
- Department of Obstetrics and Gynecology, Hôpital Maisonneuve-Rosemont, Université de Montréal, Quebec, Canada
| | - Susie Lau
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Shannon Salvador
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Walter H Gotlieb
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada; Segal Cancer Center, Lady Davis Institute of Medical Research, McGill University, Montreal, Quebec, Canada.
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A prospective study evaluating the impact of implementing ‘bundled interventions’ in reducing surgical site infections among patients undergoing surgery for gynaecological Malignancies. Eur J Obstet Gynecol Reprod Biol 2019; 243:21-25. [DOI: 10.1016/j.ejogrb.2019.10.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 10/04/2019] [Accepted: 10/08/2019] [Indexed: 01/09/2023]
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28
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Mantoani CC, Margatho AS, Dantas RAS, Galvão CM, de Campos Pereira Silveira RC. Perioperative Blood Transfusion and Occurrence of Surgical Site Infection: An Integrative Review. AORN J 2019; 110:626-634. [PMID: 31774169 DOI: 10.1002/aorn.12861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The aim of this integrative review was to locate, assess, and synthesize available evidence of the relationship between perioperative allogeneic blood transfusion and the occurrence of surgical site infection among adult patients undergoing elective surgery. After a comprehensive search of relevant databases and a review of the studies this yielded, we used a validated instrument to extract data from the 25 studies in our final sample. The clinical and surgical variables that were significantly and more frequently associated with the occurrence of surgical site infection among patients who received blood transfusions during the perioperative period were female sex, older age, and higher body mass index. Our findings indicate a lack of consensus on the hemoglobin levels that indicate a blood transfusion is necessary.
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Gezer S, Yalvaç HM, Güngör K, Yücesoy İ. Povidone-iodine vs chlorhexidine alcohol for skin preparation in malignant and premalignant gynaecologic diseases: A randomized controlled study. Eur J Obstet Gynecol Reprod Biol 2019; 244:45-50. [PMID: 31739120 DOI: 10.1016/j.ejogrb.2019.10.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 10/17/2019] [Accepted: 10/18/2019] [Indexed: 01/02/2023]
Abstract
OBJECTIVES To compare povidone-iodine with chlorhexidine alcohol solutions for the prevention of surgical site infection (SSI) in malignant and premalignant gynaecologic diseases, and to evaluate the effects of temperature on SSI at 25 °C and 37 °C. STUDY DESIGN This was a randomized controlled trial of a cohort of 220 patients undergoing surgery for malignant or premalignant conditions. Preoperative skin preparations were performed with 10% povidone-iodine at 25 °C (PI), 10% povidone-iodine at 37 °C (warm PI), 4% chlorhexidine gluconate with alcohol at 25 °C (CH) and 4% chlorhexidine gluconate with alcohol at 37 °C (warm CH) for each group. All women included in the study received 1 g intravenous cefazolin antibioprophylaxis 30 min before skin incision. The primary outcome was SSI within 30 days of surgery, and secondary outcomes were identification of the causative organism and clinical factors that may be associated with SSI. RESULTS SSIs were detected in 24 (10.9%) patients. Except for two organ/space-specific SSIs, all were superficial SSIs. The frequency of SSI was significantly lower in the warm PI group than in the PI group (p = 0.032). There were no significant differences in the frequency of SSI between the groups in other binary comparisons. In addition, there was no significant difference between both povidone-iodine groups compared with both chlorhexidine alcohol groups in terms of the development of SSI (10.9% vs 11%, p = 1.00). SSI caused by micro-organisms was found in 18 patients, and Enterococcus faecalis was the most common reproducing organism in wound culture. Patients with SSI were significantly older (58.9 ± 11.4 vs 52.8 ± 12.3 years) and more likely to be readmitted to hospital [15 (62.5%) vs 9 (37.5%)] than patients without SSI. CONCLUSIONS SSI rates can be reduced by warming povidone-iodine, but this effect could not be demonstrated with chlorhexidine solutions. When both groups of povidone-iodine were compared with both groups of chlorhexidine alcohol, no significant difference was found in the prevention of SSI in malignant and premalignant gynaecologic operations.
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Affiliation(s)
- Sener Gezer
- Kocaeli University School of Medicine, Kocaeli, Turkey.
| | | | - Kübra Güngör
- Kocaeli University School of Medicine, Kocaeli, Turkey
| | - İzzet Yücesoy
- Kocaeli University School of Medicine, Kocaeli, Turkey
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Tyan P, Taher A, Carey E, Sparks A, Radwan A, Amdur R, Tamim H, Gu A, Robinson H, Moawad GN. The effect of anemia severity on postoperative morbidity among patients undergoing laparoscopic hysterectomy for benign indications. Acta Obstet Gynecol Scand 2019; 99:112-118. [PMID: 31449328 DOI: 10.1111/aogs.13718] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/03/2019] [Accepted: 08/05/2019] [Indexed: 01/02/2023]
Abstract
INTRODUCTION One-third of non-pregnant women worldwide are anemic.1 Anemia is a known independent risk factor for postoperative morbidity.2 Given that the vast majority of hysterectomies are not performed in the emergency setting, we designed this study to evaluate the effect of preoperative anemia on postoperative morbidity following laparoscopic hysterectomy performed for benign indications. Our main goal is to encourage surgeons to use anemia-corrective measures before surgery when feasible. MATERIAL AND METHODS Retrospective cohort study of 98 813 patients who underwent a laparoscopic hysterectomy between 2005 and 2016 for benign indications identified through the American College of Surgeons National Surgical Quality Improvement Program. Anemia was examined as a function of hematocrit and was analyzed as an ordinal variable stratified by anemia severity as mild, moderate or severe. Associations between preoperative anemia and patient demographics, preoperative comorbidities and postoperative outcomes were evaluated using univariate analyses. Multivariable logistic regression models were used to identify independent associations between hematocrit level and postoperative outcomes after adjusting for confounding covariates. At the multivariable logistic regression level, anemia severity was analyzed using hematocrit as a continuous variable to assess the independent association between each 5% decrease in hematocrit level and several postoperative morbidities. RESULTS Of the 98 813 patients who met our inclusion and exclusion criteria, 19.5% were anemic. A lower preoperative hematocrit was associated with higher body mass index, younger age, Black or African American race, longer operative times, and multiple other medical comorbidities. After appropriate regression modeling, anemia was identified as an independent risk factor for extended length of stay, readmission and composite morbidity after surgery. CONCLUSIONS Preoperative anemia is common among patients undergoing laparoscopic hysterectomy. Preoperative anemia increases patients' risk for multiple postoperative comorbidities. Given that most hysterectomies are performed in the elective setting, gynecologic surgeons should consider the use of anemia-corrective measures to minimize postoperative morbidity.
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Affiliation(s)
- Paul Tyan
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Ali Taher
- Division of Hematology and Oncology, Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Erin Carey
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Andrew Sparks
- Department of Surgery, School of Medicine & Health Sciences, The George Washington University, Washington, DC, USA
| | - Amr Radwan
- Department of Internal Medicine, St. Elizabeth's Medical Center, Brighton, MA, USA
| | - Richard Amdur
- Department of Surgery, School of Medicine & Health Sciences, The George Washington University, Washington, DC, USA
| | - Hani Tamim
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Alex Gu
- School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Hannah Robinson
- School of Medicine and Health Sciences, The George Washington University, Washington, DC, USA
| | - Gaby N Moawad
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, The George Washington University, Washington, DC, USA
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Kilts TP, Glaser GE, Langstraat CL, Kumar A, Weaver AL, Mc Gree ME, Gostout BS, Podratz KC, Dowdy SC, Cliby WA, Mariani A, Bakkum-Gamez JN. Comparing risk stratification criteria for predicting lymphatic dissemination in endometrial cancer. Gynecol Oncol 2019; 155:21-26. [PMID: 31409487 DOI: 10.1016/j.ygyno.2019.08.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 07/26/2019] [Accepted: 08/02/2019] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To compare two published risk stratification models (Milwaukee Model vs. Mayo Criteria) to predict lymphatic dissemination (LD) in endometrioid endometrial cancer (EC). METHODS Patients with stage I-III EC undergoing surgery from 1/1/2004-9/30/2013 were retrospectively reviewed and classified as low-risk vs at-risk for LD using two independent risk models. LD was defined as positive nodes at surgery or lymph node recurrence within 2 years of surgery after negative lymph node dissection (LND) or when LND was not performed. False positive (FP) and false negative (FN) rates for each risk model were calculated. RESULTS Among 1103 patients, 81 (7.3%) had LD (72 positive LN and 9 LN recurrences), and most (90.2%) had stage I EC. The Milwaukee Model yielded a low at-risk rate for LD (38.1%) but a high FN rate (13.6%, 95% CI 7.0-23.0). The traditional Mayo Criteria using a cut-off of 2 cm for tumor diameter (TD) had a higher at-risk rate for LD (69.5%) but a FN rate of 0% (95% CI, 0-4.5). Modifying the Mayo Criteria using a TD cutoff of ≤3 cm identified fewer women at-risk (56.8% vs. 69.5%) and had a lower FP rate (53.6% vs. 67.1%), but had a higher FN rate (3.7%, 95% CI, 0.8-10.4). CONCLUSIONS The Milwaukee Model had the lowest at-risk rate of LD but an unacceptable FN rate. Modifying the Mayo Criteria by increasing the TD cutoff from the traditional ≤2 cm to ≤3 cm would spare an estimated 13.5% of patients LND, but the accompanying FN rate is unacceptably high. The traditional Mayo Criteria for low-risk EC remains the most sensitive in determining which patients LND can be omitted.
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Affiliation(s)
- Toni P Kilts
- Division of Gynecologic Oncology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Gretchen E Glaser
- Division of Gynecologic Oncology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Carrie L Langstraat
- Division of Gynecologic Oncology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Amanika Kumar
- Division of Gynecologic Oncology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Amy L Weaver
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, 55905, United States
| | - Michaela E Mc Gree
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, 55905, United States
| | - Bobbie S Gostout
- Division of Gynecologic Oncology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Karl C Podratz
- Division of Gynecologic Oncology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Sean C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - William A Cliby
- Division of Gynecologic Oncology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Andrea Mariani
- Division of Gynecologic Oncology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States
| | - Jamie N Bakkum-Gamez
- Division of Gynecologic Oncology, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, United States.
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Donkers H, Bekkers R, Massuger L, Galaal K. Systematic review on socioeconomic deprivation and survival in endometrial cancer. Cancer Causes Control 2019; 30:1013-1022. [DOI: 10.1007/s10552-019-01202-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 06/25/2019] [Indexed: 01/19/2023]
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Mert I, Cliby WA, Bews KA, Habermann EB, Dowdy SC. Evidence-based wound classification for vulvar surgery: Implications for risk adjustment. Gynecol Oncol 2019; 154:280-282. [PMID: 31248667 DOI: 10.1016/j.ygyno.2019.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 06/03/2019] [Accepted: 06/06/2019] [Indexed: 01/29/2023]
Abstract
OBJECTIVES The correct wound classification for vulvar procedures (VP) is ambiguous according to current definitions, and infection rates are poorly described. We aimed to analyze rates of surgical site infection (SSI) in women who underwent VP to correctly categorize wound classification. METHODS Patients who underwent VP for dysplasia or carcinoma were collected from the National Surgical Quality Improvement Program database (NSQIP). SSI rates of vulvar cases were compared to patients who underwent abdominal hysterectomy via laparotomy, stratified by the National Academy of Sciences wound classification. Descriptive analyses and trend tests of categorical variables were performed. RESULTS Between 2008 and 2016, 2116 and 31,506 patients underwent a VP or TAH, respectively. Among VP, 1345 (63.6%), 364 (17.2%), and 407 (19.2%) women underwent simple vulvectomy, radical vulvectomy, or radical vulvectomy with lymphadenectomy, respectively. The overall rate of SSI for VP was higher than that observed for TAH (5.6% vs. 3.8%; p < 0.0001). While patients undergoing TAH displayed a corresponding increase in the rate of SSI with wound type (type I: 3.4%; type II: 3.8%, type III: 6.8%; type IV 10.6%; p < 0.001), no such correlation was observed for simple VP (type I: 3.3%, type II: 3.0%; type III: 3.2%; type IV: 0%; p = 0.40). On the other hand, a non-significant correlation was observed for radical VP (type I: 4.0%, type II: 10.1%; type III: 14.3%; type IV: 20.0%; p = 0.08). The overall rate of SSI in patients undergoing any radical VP was similar to patients undergoing hysterectomy with a type IV wound (10.1% vs 10.6%, p = 0.87). CONCLUSION Patients undergoing VP are at high risk of infection. Simple vulvectomy should be classified as a type II and radical vulvectomy as a type III wound. These recommendations are important for proper risk adjustment.
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Affiliation(s)
- I Mert
- Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN, USA
| | - W A Cliby
- Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN, USA
| | - K A Bews
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Surgical Outcomes Program, Mayo Clinic, Rochester, MN, USA
| | - E B Habermann
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery Surgical Outcomes Program, Mayo Clinic, Rochester, MN, USA
| | - S C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic, Rochester, MN, USA.
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Association of preoperative anaemia with cardiopulmonary exercise capacity and postoperative outcomes in noncardiac surgery: a substudy of the Measurement of Exercise Tolerance before Surgery (METS) Study. Br J Anaesth 2019; 123:161-169. [PMID: 31227271 DOI: 10.1016/j.bja.2019.04.058] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 03/25/2019] [Accepted: 04/09/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Preoperative anaemia is associated with elevated risks of postoperative complications. This association may be explained by confounding related to poor cardiopulmonary fitness. We conducted a pre-specified substudy of the Measurement of Exercise Tolerance before Surgery (METS) study to examine the associations of preoperative haemoglobin concentration with preoperative cardiopulmonary exercise testing performance (peak oxygen consumption, anaerobic threshold) and postoperative complications. METHODS The substudy included a nested cross-sectional analysis and nested cohort analysis. In the cross-sectional study (1279 participants), multivariate linear regression modelling was used to determine the adjusted association of haemoglobin concentration with peak oxygen consumption and anaerobic threshold. In the nested cohort study (1256 participants), multivariable logistic regression modelling was used to determine the adjusted association of haemoglobin concentration, peak oxygen consumption, and anaerobic threshold with the primary endpoint (composite outcome of death, cardiovascular complications, acute kidney injury, or surgical site infection) and secondary endpoint (moderate or severe complications). RESULTS Haemoglobin concentration explained 3.8% of the variation in peak oxygen consumption and anaerobic threshold (P<0.001). Although not associated with the primary endpoint, haemoglobin concentration was associated with moderate or severe complications after adjustment for peak oxygen consumption (odds ratio=0.86 per 10 g L-1 increase; 95% confidence interval, 0.77-0.96) or anaerobic threshold (odds ratio=0.86; 95% confidence interval, 0.77-0.97). Lower peak oxygen consumption was associated with moderate or severe complications without effect modification by haemoglobin concentration (P=0.12). CONCLUSION Haemoglobin concentration explains a small proportion of variation in exercise capacity. Both anaemia and poor functional capacity are associated with postoperative complications and may therefore be modifiable targets for preoperative optimisation.
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Current practice and physicians' opinion about preoperative hair removal as a part of ERAS pathway implementation in gynecology and gynecology-oncology: a NOGGO-AGO survey of 148 gynecological departments in Germany. Arch Gynecol Obstet 2019; 299:1607-1618. [PMID: 30953189 DOI: 10.1007/s00404-019-05132-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 03/25/2019] [Indexed: 12/27/2022]
Abstract
PURPOSE To gather standardized information about current practices and doctors' opinions on preoperative hair removal (PHR) from the surgical site and to evaluate the extent of PHR as one of the elements of enhanced recovery after surgery (ERAS) pathways that is established in the clinical routine in gynecology and gynecology-oncology departments in Germany. METHODS We performed a nationwide survey among 638 primary, secondary and tertiary health care gynecological departments in Germany. Data were obtained by sending a multiple-choice questionnaire about preoperative management of hair removal. The authors also evaluated the awareness of doctors regarding PHR as well as the method and time frames of PHR. The results were compared to the existing standard of procedure (SOP) and guidelines. RESULTS 148 units (23.2%) took part in the survey; participants in the survey were mostly chief physicians in 47.3% of the cases. Half (50.7%) of all the responses came from certified gynecological cancer centers. A SOP regarding PHR was reported as present in 113 clinics (76.4%). 83.8% of all units are performing PHR for midline laparotomy, 52.7% in laparoscopic operations, and 45.3% in vaginal operations. 48% used a clipper, while 43.2% utilized a single-use razor. 56.1% shaved instantly before the operation, whereas 35.8% did it the day before and earlier. 40.3% of chief physicians believe that PHR causes more surgical site infections (SSI) compared to only 11.5% of junior doctors. CONCLUSION PHR in gynecological departments in Germany is performed very heterogeneously and SOPs are often not based on guidelines and ERAS principles. Around one-third of the German gynecological clinics keep strictly to the guidelines. The awareness on PHR and SSI among junior doctors is very low.
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Monsour MA, Wiley W, Le CH, Lee J, Brown KP, Robinson M, Elsamadicy EA. Infectious Causes of 30-Day Unplanned Hospital Encounters and Readmissions After Hysterectomies: A Single Institutional Study. J Gynecol Surg 2019. [DOI: 10.1089/gyn.2018.0052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Meredith A. Monsour
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Whittney Wiley
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Chi H. Le
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Jaclyn Lee
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Kelsei P. Brown
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Marc Robinson
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Emad A. Elsamadicy
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
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Nelson G, Bakkum-Gamez J, Kalogera E, Glaser G, Altman A, Meyer LA, Taylor JS, Iniesta M, Lasala J, Mena G, Scott M, Gillis C, Elias K, Wijk L, Huang J, Nygren J, Ljungqvist O, Ramirez PT, Dowdy SC. Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update. Int J Gynecol Cancer 2019; 29:651-668. [PMID: 30877144 DOI: 10.1136/ijgc-2019-000356] [Citation(s) in RCA: 391] [Impact Index Per Article: 78.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 02/18/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND This is the first updated Enhanced Recovery After Surgery (ERAS) Society guideline presenting a consensus for optimal perioperative care in gynecologic/oncology surgery. METHODS A database search of publications using Embase and PubMed was performed. Studies on each item within the ERAS gynecologic/oncology protocol were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly. CONCLUSIONS The updated evidence base and recommendation for items within the ERAS gynecologic/oncology perioperative care pathway are presented by the ERAS® Society in this consensus review.
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Affiliation(s)
- Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Jamie Bakkum-Gamez
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Eleftheria Kalogera
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Gretchen Glaser
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Alon Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maria Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Javier Lasala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gabriel Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Scott
- Department of Anesthesia, Virginia Commonwealth University Hospital, Richmond, Virginia, USA
| | - Chelsia Gillis
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Kevin Elias
- Division of Gynecologic Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Lena Wijk
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Jeffrey Huang
- Department of Anesthesiology, Oak Hill Hospital, Brooksville, Florida, USA
| | - Jonas Nygren
- Departments of Surgery and Clinical Sciences, Ersta Hospital and Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sean C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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Type of Pelvic Disease as a Risk Factor for Surgical Site Infectionin Women Undergoing Hysterectomy. J Minim Invasive Gynecol 2018; 26:1149-1156. [PMID: 30508651 DOI: 10.1016/j.jmig.2018.11.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 11/21/2018] [Accepted: 11/27/2018] [Indexed: 02/01/2023]
Abstract
STUDY OBJECTIVE To quantify the relationship between type of benign pelvic disease and risk of surgical site infection (SSI) after hysterectomy. DESIGN Retrospective cohort study (Canadian Task Force classification II-2). SETTING Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). PATIENTS Women who underwent hysterectomy from 2006-2015 and recorded in NSQIP database. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS SSI risk was compared for type of benign pelvic disease, patient characteristics (i.e., age, race, and selected comorbidities) and process of care variables (i.e., admission status, type of hysterectomy, and operative time). SSI occurred in 2.48% of the 125,337 women who underwent hysterectomy. SSI was most frequent in patients with endometriosis and least frequent in those with genital prolapse (3.13% vs 1.39%; p <.0001). Following adjustment for potential confounders, the odds of SSI were higher in women undergoing hysterectomy for endometriosis (adjusted odds ratio [aOR], 1.79; 95% confidence interval [CI], 1.43- 2.25), uterine myomas (aOR, 1.28; 95% CI, 1.05-1.55), menstrual disorders (aOR, 1.46; 95% CI, 1.20-1.78), and pelvic pain (aOR, 1.75; 95% CI, 1.34-2.27) compared with women undergoing hysterectomy for genital prolapse. Other patient factors associated with SSI included age, body mass index, smoking, diabetes mellitus, chronic obstructive pulmonary disease, hypertension, and American Society of Anesthesiologists classification. Among process-of-care factors, inpatient status, route of hysterectomy, total vs subtotal hysterectomy, and operative time were also associated with SSI. CONCLUSION In addition to various patient and process-of-care factors known to be associated with SSI, type of underlying pelvic disease is an independent risk factor for SSI in women undergoing hysterectomy for benign indications.
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Aapro M, Beguin Y, Bokemeyer C, Dicato M, Gascón P, Glaspy J, Hofmann A, Link H, Littlewood T, Ludwig H, Österborg A, Pronzato P, Santini V, Schrijvers D, Stauder R, Jordan K, Herrstedt J. Management of anaemia and iron deficiency in patients with cancer: ESMO Clinical Practice Guidelines. Ann Oncol 2018; 29:iv96-iv110. [PMID: 29471514 DOI: 10.1093/annonc/mdx758] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Affiliation(s)
- M Aapro
- Genolier Cancer Centre, Clinique de Genolier, Genolier, Switzerland
| | - Y Beguin
- University of Liège, Liège
- CHU of Liège, Liège, Belgium
| | - C Bokemeyer
- Department of Oncology, Hematology and BMT with Section Pneumology, University of Hamburg, Hamburg, Germany
| | - M Dicato
- Hématologie-Oncologie, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - P Gascón
- Department of Haematology-Oncology, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - J Glaspy
- Division of Hematology and Oncology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, USA
| | - A Hofmann
- Medical Society for Blood Management, Laxenburg, Austria
| | - H Link
- Klinik für Innere Medizin I, Westpfalz-Klinikum, Kaiserslautern, Germany
| | - T Littlewood
- Department of Haematology, John Radcliffe Hospital, Oxford, UK
| | - H Ludwig
- Wilhelminen Cancer Research Institute, Wilhelminenspital, Vienna, Austria
| | - A Österborg
- Karolinska Institute and Karolinska Hospital, Stockholm, Sweden
| | - P Pronzato
- Medica Oncology, IRCCS Asiana Pedaliter Universitaria San Martino - IST, Institutor Nazionale per la Ricercars sol Chancre, Genova
| | - V Santini
- Department of Experimental and Clinical Medicine, Haematology, University of Florence, Florence, Italy
| | - D Schrijvers
- Department of Medical Oncology, Ziekenhuisnetwerk Antwerpen, Antwerp, Belgium
| | - R Stauder
- Department of Internal Medicine V (Haematology and Oncology), Innsbruck Medical University, Innsbruck, Austria
| | - K Jordan
- Department of Medicine V, University of Heidelberg, Heidelberg, Germany
| | - J Herrstedt
- Department of Oncology, Zealand University Hospital Roskilde, Roskilde
- University of Copenhagen, Copenhagen, Denmark
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Toba M, Moriwaki M, Oshima N, Aiso Y, Shima M, Nukui Y, Obayashi S, Fushimi K. Prevention of surgical site infection via antibiotic administration according to guidelines after gynecological surgery. J Obstet Gynaecol Res 2018; 44:1800-1807. [PMID: 30051538 DOI: 10.1111/jog.13714] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 05/25/2018] [Indexed: 12/13/2022]
Abstract
AIM We modified the antimicrobial prophylaxis of surgical site infection (SSI) according to the guidelines of the Japanese Society of Chemotherapy and Japan Society of Infectious Diseases (hereinafter referred to as optimization) and measured outcomes. METHODS From April 2016 to March 2017, we performed cesarean section and open hysterectomy with optimization, and compared the outcome to that of surgery performed without optimization between April 2014 and March 2016. We measured the rates of antibiotic discontinuation, appropriate antibiotic selection, SSI incidence, resumption of antibiotic therapy and fever incidence, as well as the length of postoperative hospital stay and medical expenses for antibiotics to evaluate the appropriateness and outcomes of antibiotic prophylaxis. RESULTS Optimization resulted in a change in the method of selecting antibiotics for cesarean section, but there was no change in SSI incidence rate (0.74% vs 0.0%, P = 0.36). Optimization reduced the use of antibiotics and medical expenses of hysterectomy (median reduction of 50% and 78% for hysterectomy without or with lymphadenectomy, respectively). However, there was no change in outcome regarding SSI incidence (5.7% vs 0.0%, P = 0.11 and 7.8% vs 9.5%, P = 0.77, respectively). CONCLUSION Appropriate use of antibiotics according to guidelines reduced antibiotic dose and medical expenses, but there was no change in outcome regarding SSI incidence rate. These findings suggested that implementation of dosing regimens according to the guidelines would be useful to reduce antibiotic medicine costs and prevent resistant bacteria and complications associated with antibiotics.
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Affiliation(s)
- Mikayo Toba
- Quality Management Center, Tokyo Medical and Dental University, Tokyo, Japan.,Perinatal and Women's Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Mutsuko Moriwaki
- Quality Management Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Noriko Oshima
- Perinatal and Women's Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoshibumi Aiso
- Division of Infection Control and Prevention, Tokyo Medical and Dental University, Tokyo, Japan
| | - Mari Shima
- Division of Infection Control and Prevention, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoko Nukui
- Division of Infection Control and Prevention, Tokyo Medical and Dental University, Tokyo, Japan
| | - Satoshi Obayashi
- Perinatal and Women's Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kiyohide Fushimi
- Quality Management Center, Tokyo Medical and Dental University, Tokyo, Japan.,Department of Health Policy and Informatics, Tokyo Medical and Dental University, Tokyo, Japan
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Wallace SK, Halverson JW, Jankowski CJ, DeJong SR, Weaver AL, Weinhold MR, Borah BJ, Moriarty JP, Cliby WA, Kor DJ, Higgins AA, Otto HA, Dowdy SC, Bakkum-Gamez JN. Optimizing Blood Transfusion Practices Through Bundled Intervention Implementation in Patients With Gynecologic Cancer Undergoing Laparotomy. Obstet Gynecol 2018; 131:891-898. [PMID: 29630007 PMCID: PMC5912961 DOI: 10.1097/aog.0000000000002463] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To examine blood transfusion practices and develop a standardized bundle of interventions to address the high rate of perioperative red blood cell transfusion among patients with ovarian and endometrial cancer. METHODS This was a retrospective cohort study. Our primary aim was to determine whether an implemented bundled intervention was associated with a reduction in perioperative red blood cell transfusions among cases of laparotomy for cancer. Secondary aims included comparing perioperative demographic, surgical, complication, and cost data. Interventions included blood transfusion practice standardization using American Society of Anesthesiologists guidelines, an intraoperative hemostasis checklist, standardized intraoperative fluid status communication, and evidence-based use of tranexamic acid. Prospective data from women undergoing laparotomy for ovarian or endometrial cancer from September 28, 2015, to May 31, 2016, defined the study cohort and were compared with historical controls (September 1, 2014, to September 25, 2015). Outcomes were compared in the full unadjusted cohorts and in propensity-matched cohorts. RESULTS In the intervention and historical cohorts, respectively, 89 and 184 women underwent laparotomy for ovarian cancer (n=74 and 152) or advanced endometrial cancer (n=15 and 32). Tranexamic acid was administered in 54 (60.7%) patients. The perioperative transfusion rate was lower for the intervention group compared with historical controls (18.0% [16/89] vs 41.3% [76/184], P<.001), a 56.4% reduction. This improvement in the intervention group remained significant after propensity matching (16.2% [13/80] vs 36.2% [29/80], P=.004). The hospital readmission rate was also lower for the intervention group compared with historical controls (1.1% [1/89] vs 12.5% [23/184], P=.002); however, this improvement did not attain statistical significance after propensity matching (1.2% [1/80] vs 7.5% [6/80], P=.12). Cost analysis demonstrated that this intervention was cost-neutral during index hospitalization plus 30-day follow-up. CONCLUSION Application of a standardized bundle of evidence-based interventions was associated with reduced blood use in our gynecologic oncology practice.
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Affiliation(s)
- Sumer K. Wallace
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, Minnesota
| | - Jessica W. Halverson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | | | - Stephanie R. DeJong
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, Minnesota
| | - Amy L. Weaver
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Megan R. Weinhold
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, Minnesota
| | - Bijan J. Borah
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester MN
| | - James P. Moriarty
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester MN
| | - William A. Cliby
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, Minnesota
| | - Daryl J. Kor
- Department of Anesthesiology and Perioperative Medicine, Blood Management Program, Mayo Clinic, Rochester, MN
| | - Andrew A. Higgins
- Department of Anesthesiology and Perioperative Medicine, Blood Management Program, Mayo Clinic, Rochester, MN
| | - Hilary A. Otto
- Department of Surgery, Division of Surgical Services, Mayo Clinic, Rochester, MN
| | - Sean C. Dowdy
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, Minnesota
- Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester MN
| | - Jamie N. Bakkum-Gamez
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Mayo Clinic, Rochester, Minnesota
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Kamei J, Yazawa S, Yamamoto S, Kaburaki N, Takahashi S, Takeyama M, Koyama M, Homma Y, Arakawa S, Kiyota H. Risk factors for surgical site infection after transvaginal mesh placement in a nationwide Japanese cohort. Neurourol Urodyn 2018. [PMID: 29527737 DOI: 10.1002/nau.23416] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
AIMS We conducted a nationwide survey on perioperative management and antimicrobial prophylaxis of transvaginal mesh surgeries for pelvic organ prolapse in Japan to understand the practice and risk factors for surgical site infection (SSI). METHODS Health records of women undergoing tension-free vaginal mesh (TVM) surgeries from 2010 to 2012 were obtained from 135 medical centers belonging to the Japanese Society of Pelvic Organ Prolapse Surgery. The questionnaire addressed hospital volume, perioperative management, and SSI. Risk factors for SSI were investigated by comparing cases with and without SSI. RESULTS The hospital volume among institutions varied from 0 to 248 per year (median 16.7). Preoperative hair removal, bowel preparation, and urine culture were routinely performed at 74 (55%), 66 (49%), and 24 (18%) hospitals, respectively. Prophylactic antimicrobials used were mostly first-generation (43%) or second-generation (42%) cephalosporin. SSI was reported in 86 of 9323 patients (0.92%). A multivariate analysis indicated lower hospital volume (odds ratio [OR], 0.995 [by 1-point increase]; P < 0.001), preoperative bowel preparation (OR, 2.08; P = 0.013), non-routine urine culture (OR, 3.00; P = 0.0006), and the use of antibiotics other than first-generation cephalosporin (OR, 5.29; P = 0.0011) as significant risk factors for SSI. In contrast, the cut-off points of hospital volume for preventing SSI was 116.7 cases (area under curve: 0.61). CONCLUSION The prevalence of SSI in TVM surgeries was 0.92% in Japan. Lower hospital volume, bowel preparation, non-routine preoperative urine culture, and prophylactic antibiotics other than first-generation cephalosporin significantly elevated the incidence of SSI.
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Affiliation(s)
- Jun Kamei
- Department of Urology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan.,The Japanese Research Group for Urinary Tract Infection (JRGU), Japan
| | - Satoshi Yazawa
- The Japanese Research Group for Urinary Tract Infection (JRGU), Japan.,Yazawa Clinic, Saitama, Japan.,Department of Urology, School of Medicine, Keio University, Tokyo, Japan
| | - Shingo Yamamoto
- The Japanese Research Group for Urinary Tract Infection (JRGU), Japan.,Department of Urology, Hyogo College of Medicine, Hyogo, Japan
| | - Naoto Kaburaki
- The Japanese Research Group for Urinary Tract Infection (JRGU), Japan.,Department of Urology, School of Medicine, Keio University, Tokyo, Japan
| | - Satoru Takahashi
- Department of Urology, Nihon University School of Medicine, Tokyo, Japan.,The Japanese Society of Pelvic Organ Prolapse Surgery (JPOPS), Japan
| | - Masami Takeyama
- Urogynecology Center, First Towakai Hospital, Osaka, Japan.,The Japanese Society of Pelvic Organ Prolapse Surgery (JPOPS), Japan
| | - Masayasu Koyama
- Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, Osaka, Japan.,The Japanese Society of Pelvic Organ Prolapse Surgery (JPOPS), Japan
| | - Yukio Homma
- Department of Urology, The University of Tokyo Graduate School of Medicine, Tokyo, Japan.,Department of Urology, Japan Red Cross Medical Center, Tokyo, Japan
| | - Soichi Arakawa
- The Japanese Research Group for Urinary Tract Infection (JRGU), Japan.,Department of Urology, Sanda City Hospital, Hyogo, Japan
| | - Hiroshi Kiyota
- The Japanese Research Group for Urinary Tract Infection (JRGU), Japan.,Department of Urology, Jikei University School of Medicine, Katsushika Medical Center, Tokyo, Japan
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Primary Placement of Incisional Negative Pressure Wound Therapy at Time of Laparotomy for Gynecologic Malignancies. Int J Gynecol Cancer 2018; 26:1525-9. [PMID: 27488215 DOI: 10.1097/igc.0000000000000792] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Wound complications are an important cause of postoperative morbidity amongst patient with gynecologic malignancies. We evaluated whether the placement of prophylactic negative pressure wound therapy (NPWT) at the time of laparotomy for gynecologic cancer surgery reduces wound complication rates. METHODS A retrospective analysis of patients undergoing laparotomy with primary wound closure performed by a gynecologic oncologist at a single academic institution over a 5-year study period was performed. Patients who had placement of prophylactic NPWT dressing were compared with patients with a standard closure. Postoperative outcomes were examined. RESULTS A total of 230 patients were identified: 208 women received standard wound care, 22 received NPWT. Groups were similar in age, prevalence of diabetes, tobacco use, and number of previous abdominal procedures. Intraoperative factors including length of procedure and transfusion requirements were similar. Body mass index for patients receiving standard treatment was 30.67 compared with 41.29 for NPWT group (P < 0.001). Incidence of all wound complications was 19.7% for those receiving standard treatment versus 27.3% for NPWT group (P = 0.40). Length of hospital stay was similar between the 2 groups (5.25 vs 6.22 days, P = 0.20). There were 3 hospital readmissions for wound complications-none occurred in women with a prophylactic NPWT dressing. CONCLUSIONS Despite significantly higher obesity rates, patients with prophylactic NPWT dressing placement had similar rates of wound complications. Our findings suggest a potential therapeutic benefit in the use of prophylactic NPWT for the reduction of wound complications in this high-risk gynecologic oncology patient population.
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Gali B, Bakkum-Gamez JN, Plevak DJ, Schroeder D, Wilson TO, Jankowski CJ. Perioperative Outcomes of Robotic-Assisted Hysterectomy Compared With Open Hysterectomy. Anesth Analg 2018; 126:127-133. [PMID: 28430689 DOI: 10.1213/ane.0000000000001935] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Increasing numbers of robotic hysterectomies (RH) are being performed. To provide ventilation (with pneumoperitoneum and steep Trendelenburg position) for these procedures, utilization of lung protective strategies with limiting airway pressures and tidal volumes is difficult. Little is known about the effects of intraoperative mechanical ventilation and high peak airway pressures on perioperative complications. We performed a retrospective review to determine whether patients undergoing RH had increased pulmonary complications compared to total abdominal hysterectomy (TAH). METHODS We performed a single center retrospective review comparing the intraoperative, anesthetic, and immediate and 30-day postoperative course of patients undergoing RH to TAH, including intraoperative ventilatory parameters and respiratory complications. Patients undergoing TAH (201) from 2004 to 2006 were compared to RH (251) from 2009 to 2012. It was our hypothesis that patients undergoing RH would have increased incidence of postoperative pulmonary complications. A secondary hypothesis was that morbid obesity predicts pulmonary complications in patients undergoing RH. Complications were compared between groups using Fisher's exact test. To account for potential confounders, the primary analysis was performed for a subgroup of patients matched on the propensity for RH. RESULTS A total of 351 RH and 201 TAH procedures are included. Higher inspiratory pressures were required in ventilation of the RH group (median [25th, 75th] 31 [26, 36] cm H2O) than the TAH group (23 [19, 27] cm H2O) (P < .001) at 30 minutes after incision. Peak inspiratory pressures at 30 minutes after incision for RH increased according to increasing body mass index group (P < .001). There were 163 RH and 163 TAH procedures included in the propensity matched analysis. From this analysis, there were no significant differences in cardiopulmonary complications between RH and TAH (0.6% vs 1.2%; odds ratio = 2.0, 95% confidence interval = 0.2-2.4; P = 1.00). Surgical site infection was significantly lower in the RH compared to TAH group (0.6% vs 8.6%; P < .001). Hospital length of stay was longer for those who underwent TAH versus RH (median [25th, 75th] 2 [2, 3] vs 1 [0, 2] days; P < .001). CONCLUSIONS There was no significant difference in perioperative complications in obese and morbidly obese women compared to nonobese undergoing RH. Patients undergoing RH had shorter hospital stays, fewer infectious complications, and no increase in overall complications compared to TAH. Higher ventilatory airway pressures (RH versus TAH and obese versus nonobese) did not result in an increase in cardiopulmonary or overall complications. We believe that peritoneal insufflation attenuates the effect of high airway pressures by raising intrapleural pressure and reducing the gradient across terminal bronchioles and alveoli. Thus, we propose that lung protective strategies for patients undergoing RH account for the markedly elevated intraperitoneal and intrapleural pressures, whereas transpulmonary airway pressures remain static. This reduced transpulmonary gradient attenuates the strain on lung tissue that would otherwise be imposed by ventilation at high pressures.
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Affiliation(s)
| | | | | | - Darrell Schroeder
- Division of Biomedical Statistics & Informatics, Mayo Clinic, Rochester, Minnesota
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Ducie JA, Eriksson AGZ, Ali N, McGree ME, Weaver AL, Bogani G, Cliby WA, Dowdy SC, Bakkum-Gamez JN, Soslow RA, Keeney GL, Abu-Rustum NR, Mariani A, Leitao MM. Comparison of a sentinel lymph node mapping algorithm and comprehensive lymphadenectomy in the detection of stage IIIC endometrial carcinoma at higher risk for nodal disease. Gynecol Oncol 2017; 147:541-548. [DOI: 10.1016/j.ygyno.2017.09.030] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 09/25/2017] [Accepted: 09/26/2017] [Indexed: 11/15/2022]
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Surgical-site infection in gynecologic surgery: pathophysiology and prevention. Am J Obstet Gynecol 2017; 217:121-128. [PMID: 28209490 DOI: 10.1016/j.ajog.2017.02.014] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 01/25/2017] [Accepted: 02/07/2017] [Indexed: 11/21/2022]
Abstract
Surgical-site infections (SSIs) represent a well-known cause of patient morbidity as well as added health care costs. In gynecologic surgery, particularly hysterectomy, SSIs are often the result of a number of risk factors that may or may not be modifiable. As both the Centers for Medicaid and Medicare Services and the Joint Commission on the Accreditation of Healthcare Organizations have identified SSIs as a patient safety priority, gynecologic surgeons continue to seek out the most effective interventions for SSI prevention. This review studies the epidemiology and pathophysiology of SSIs in gynecologic surgery and evaluates the current literature regarding possible interventions for SSI prevention, both as individual measures and as bundles. Data from the obstetrical and general surgery literature will be reviewed when gynecological data are either unclear or unavailable. Practitioners and hospitals may use this information as they develop strategies for SSI prevention in their own practice.
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Reducing infection rates through perioperative glycemic control - how sweet it is. Gynecol Oncol 2017; 146:215-216. [PMID: 28716378 DOI: 10.1016/j.ygyno.2017.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Outcomes and Postoperative Complications After Hysterectomies Performed for Benign Compared With Malignant Indications. Obstet Gynecol 2017; 128:467-475. [PMID: 27500339 DOI: 10.1097/aog.0000000000001591] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare complications and outcomes after hysterectomy for benign compared with malignant indications in the United States. METHODS Women who underwent hysterectomy in the United States for either benign or malignant indications from January 2008 to December 2012 were retrospectively identified using the National Surgical Quality Improvement Program database. Patients were excluded if the procedure was not performed for primary gynecologic indications. Appropriate procedures were identified using Current Procedural Terminology and International Classification of Diseases, 9th Revision codes. Univariate and multivariable models for complication risk were estimated using logistic regression. RESULTS We identified 59,525 eligible patients, with 49,331 (82.9%) hysterectomies performed for benign and 10,194 (17.1%) for malignant indications. All complications, including wound complications (2.5% benign compared with 5.5% malignant, P<.001), venous thromboembolism (0.33% compared with 1.7%, P<.001), urinary tract infection (2.7% compared with 3.2%, P=.009), sepsis (0.53% compared with 1.9%, P<.001), blood transfusion (2.6% compared with 11.5%, P<.001), death (0.02% compared with 0.10%, P<.001), unplanned readmission (1.8% compared with 4.5%, P<.001), and returns to the operating room (0.91% compared with 1.4%, P<.001), were significantly more common for malignant hysterectomies. The overall rate of complications for benign cases was 7.9% compared with a rate of 19.4% for malignant hysterectomy. The median operating time for laparoscopy in benign cases was significantly longer than for open or vaginal hysterectomy procedures (127 minutes compared with 105 or 94 minutes, respectively; P<.001). The median operating time in malignant cases was significantly longer than for benign cases (P<.001). CONCLUSION Hysterectomies performed for gynecologic malignancies are associated with a more than twofold higher complication rate compared with those performed for benign conditions. Minimally invasive surgery is associated with a decreased complication rate compared with open surgery. These data can be used for patient counseling and surgical planning, determining physician and hospital costs of care, and considered when assigning value-based reimbursement.
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Schmitt JJ, Carranza Leon DA, Occhino JA, Weaver AL, Dowdy SC, Bakkum-Gamez JN, Pasupathy KS, Gebhart JB. Determining Optimal Route of Hysterectomy for Benign Indications: Clinical Decision Tree Algorithm. Obstet Gynecol 2017; 129:130-138. [PMID: 27926638 PMCID: PMC5217714 DOI: 10.1097/aog.0000000000001756] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate practice change after initiation of a robotic surgery program using a clinical algorithm to determine the optimal surgical approach to benign hysterectomy. METHODS A retrospective postrobot cohort of benign hysterectomies (2009-2013) was identified and the expected surgical route was determined from an algorithm using vaginal access and uterine size as decision tree branches. We excluded the laparoscopic hysterectomy route. A prerobot cohort (2004-2005) was used to evaluate a practice change after the addition of robotic technology (2007). Costs were estimated. RESULTS Cohorts were similar in regard to uterine size, vaginal parity, and prior laparotomy history. In the prerobot cohort (n=473), 320 hysterectomies (67.7%) were performed vaginally and 153 (32.3%) through laparotomy with 15.1% (46/305) performed abdominally when the algorithm specified vaginal hysterectomy. In the postrobot cohort (n=1,198), 672 hysterectomies (56.1%) were vaginal; 390 (32.6%) robot-assisted; and 136 (11.4%) abdominal. Of 743 procedures, 38 (5.1%) involved laparotomy and 154 (20.7%) involved robotic technique when a vaginal approach was expected. Robotic hysterectomies had longer operations (141 compared with 59 minutes, P<.001) and higher rates of surgical site infection (4.7% compared with 0.2%, P<.001) and urinary tract infection (8.1% compared with 4.1%, P=.05) but no difference in major complications (P=.27) or readmissions (P=.27) compared with vaginal hysterectomy. Algorithm conformance would have saved an estimated $800,000 in hospital costs over 5 years. CONCLUSION When a decision tree algorithm indicated vaginal hysterectomy as the route of choice, vaginal hysterectomy was associated with shorter operative times, lower infection rate, and lower cost. Vaginal hysterectomy should be the route of choice when feasible.
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Affiliation(s)
- Jennifer J Schmitt
- Divisions of Gynecologic Surgery, Biomedical Statistics and Informatics, Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota
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