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Burnett AF, Pitman TC, Baekelandt JF. vNOTES (vaginal natural orifice transluminal surgery) gynecologic procedures in morbidly and super-morbidly obese women: five year experience. Arch Gynecol Obstet 2024; 309:565-570. [PMID: 37880384 DOI: 10.1007/s00404-023-07250-y] [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: 05/15/2023] [Accepted: 10/01/2023] [Indexed: 10/27/2023]
Abstract
PURPOSE To analyze our experience with vNOTES gynecologic procedures in women with morbid and super morbid obesity to determine feasibility and compare outcomes with standard minimally invasive techniques. METHODS Gynecologic procedures performed by three surgeons on women with a body mass index (BMI) ≥ 40 kg/m2 from 2017 to 2023. A subset of women with a BMI ≥ 50 kg/m2 was also analyzed. RESULTS 103 women with a BMI ≥ 40 kg/m2 were identified (Class IV), 19 of whom had a BMI ≥ 50 kg/m2 (Class V). For the entire population the mean BMI was 45.7 kg/m2 (40-62). 29 women were nulliparous and 23 had at least one prior cesarean delivery. 51 had no prior abdominal surgery. The procedures performed were hysterectomy and removal of adnexae in 77 patients, hysterectomy alone in six, adnexal surgery alone in nine, and hysterectomy with adnexectomy and lymph nodes in five. Two surgeries were converted to laparoscopy and five to laparotomy. Average surgical time was 87 min (30-232). Average blood loss was 82 mL (10-400). Mean uterine weight was 206 g (29-2890). 53 procedures were performed as outpatient, 44 had overnight observation, four had a length of stay of 2 days, one each for 4 days and 5 days. The laparoscopies occurred in one patient with an obliterated cul-de-sac and in one patient for lymph node removal. The laparotomies occurred for adnexal adhesions in one, bleeding in two, a cystotomy in one requiring urology consultation, and an obliterated cul-de-sac One patient developed a postoperative vaginal cuff hematoma not requiring intervention. CONCLUSION vNOTES gynecologic procedures are feasible in this high-risk population and may result in shorter recovery times and fewer complications than standard laparoscopy or transvaginal surgery. What does this study add to the clinical work: VNOTES approach is feasible in morbidly obese women and may have distinct advantages over conventional laparoscopic, vaginal or open techniques.
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Affiliation(s)
- Alexander F Burnett
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Arkansas for Medical Sciences, 4301 West Markham Street, Slot 793, Little Rock, Arkansas, 72205, USA.
| | - Thomas C Pitman
- Baptist Medical Group Desoto Women's Consultants, Core Faculty, Baptist Memorial Hospital OB/GYN, Residency, Memphis, TN, USA
| | - Jan F Baekelandt
- Division of Gynecologic Oncology, Imelda Hospital, Bonheiden, Belgium
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Lee MW, Vallejo A, Mandelbaum RS, Yessaian AA, Pham HQ, Muderspach LI, Roman LD, Klar M, Wright JD, Matsuo K. Temporal trends of failure-to-rescue following perioperative complications in vulvar cancer surgery in the United States. Gynecol Oncol 2023; 177:1-8. [PMID: 37597497 DOI: 10.1016/j.ygyno.2023.08.002] [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: 05/31/2023] [Revised: 07/09/2023] [Accepted: 08/09/2023] [Indexed: 08/21/2023]
Abstract
OBJECTIVE Failure-to-rescue, defined as mortality following a perioperative complication, is a perioperative quality indicator studied in various surgeries, but not in vulvar cancer surgery. The objective of this study was to assess failure-to-rescue in patients undergoing surgical therapy for vulvar cancer. METHODS This cross-section study queried the National Inpatient Sample. The study population was 31,077 patients who had surgical therapy for vulvar cancer from 1/2001-9/2015. The main outcomes were (i) perioperative morbidity (29 indicators) and (ii) mortality following a perioperative complication during the index admission for vulvar surgery (failure-to-rescue), assessed with a multivariable binary logistic regression model. RESULTS The cohort-level median age was 69 years, and 14,337 (46.1%) had medical comorbidity. Perioperative complications were reported in 4736 (15.2%) patients during the hospital admission for vulvar surgery. In multivariable analysis, patient factors including older age, medical comorbidity, and morbid obesity, and treatment factors with prior radiotherapy and radical vulvectomy were associated with perioperative complications (P < 0.05). The number of patients with morbid obesity, higher comorbidity index, and prior radiotherapy increased over time (P-trends < 0.001). Among 4736 patients who developed perioperative complications, 55 patients died during the hospital admission for vulvar surgery (failure-to-rescue rate, 1.2%). In multivariable analysis, cardiac arrest (adjusted-odds ratio [aOR] 27.25), sepsis or systemic inflammatory response syndrome (aOR 11.54), pneumonia (aOR 6.03), shock (aOR 4.37), and respiratory failure (aOR 3.10) were associated with failure-to-rescue (high-risk morbidities). There was an increasing trend of high-risk morbidities from 2.0% to 3.7% over time, but the failure-to-rescue from high-risk morbidities decreased from 9.1% to 2.8% (P-trend < 0.05). CONCLUSION Vulvar cancer patients undergoing surgical treatment had increased comorbidity over time with an increase in high-risk complications. However, failure-to-rescue rate has decreased significantly.
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Affiliation(s)
- Matthew W Lee
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Andrew Vallejo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Rachel S Mandelbaum
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA; Division of Reproductive Endocrinology & Infertility, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Annie A Yessaian
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Huyen Q Pham
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Laila I Muderspach
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Lynda D Roman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Maximilian Klar
- Department of Obstetrics and Gynecology, University of Freiburg Faculty of Medicine, Freiburg, Germany
| | - Jason D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA.
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Opoku AA, Onifade RA, Odukoya OA. Challenges of morbid obesity in gynecological practice. Best Pract Res Clin Obstet Gynaecol 2023; 90:102379. [PMID: 37473647 DOI: 10.1016/j.bpobgyn.2023.102379] [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: 05/26/2023] [Revised: 06/14/2023] [Accepted: 06/22/2023] [Indexed: 07/22/2023]
Abstract
Obesity is currently a global pandemic, with increasing trends worldwide. Data from the WHO, US CDC, and the UK show an increasing trend, with 50% and 25% of the US population expected to be obese and morbidly obese by 2030. Obesity affects several aspects of health, with increased risks of cardiovascular disease, diabetes, metabolic syndrome, and several malignancies. Morbid obesity significantly impacts several aspects of female life and health, from adolescence, through the reproductive years, to the postmenopausal age group. In gynecology, there is a higher prevalence of menstrual disorders and infertility and reduced success rates of assisted reproduction; increased risk of miscarriage; pelvic organ prolapse; and endometrial, ovarian, and breast cancers. Surgery in the patient with morbid obesity is associated with several logistical challenges as well as increased surgical and peri-operative risks and increased cost. In this review, we provide an overview of the current literature, with a focus on challenges of morbid obesity in gynecological practice.
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Affiliation(s)
- Albert A Opoku
- Al Wakra Hospital, Hamad Medical Corporation, P. O. Box 82228, Al Wakra, Qatar; Weill Cornell Medical College, P. O. Box 24144, Doha, Qatar.
| | - Richard Adedamola Onifade
- Al Wakra Hospital, Hamad Medical Corporation, P. O. Box 82228, Al Wakra, Qatar; Weill Cornell Medical College, P. O. Box 24144, Doha, Qatar.
| | - Olusegun A Odukoya
- Al Wakra Hospital, Hamad Medical Corporation, P. O. Box 82228, Al Wakra, Qatar.
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Mohammad HF, Alqenawy HB, Moharram AE, Raafat TA, Abdelrahman RM. A Randomized Clinical Trial Comparing Laparoscopic and Vaginal Hysterectomy for Benign Disease: An Egyptian University Hospital Experience. J Gynecol Surg 2022. [DOI: 10.1089/gyn.2022.0067] [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)
- Hayam Fathy Mohammad
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Hamdy Bakry Alqenawy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ahmed Ezzat Moharram
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Tarek Aly Raafat
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Rehab M. Abdelrahman
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Ma B, Hao J, Xu H, Liu L, Wang W, Chen S, Wu H. Rutin promotes white adipose tissue "browning" and brown adipose tissue activation partially through the calmodulin-dependent protein kinase kinase β/AMP-activated protein kinase pathway. Endocr J 2022; 69:385-397. [PMID: 34719526 DOI: 10.1507/endocrj.ej21-0441] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Promoting white adipose tissue (WAT) "browning" and brown adipose tissue (BAT) activation could contribute to increasing energy expenditure. We explored the mechanisms by which the natural compound rutin induced adipose tissue differentiation and ameliorated obesity in vivo and in vitro. 3T3-L1 preadipocytes were cultured in adipogenic differentiation media with/out rutin. Male C57BL/6 mice (n = 6) were fed a high-fat diet (HFD) for 12 weeks with/out rutin. In HFD-fed mice, rutin treatment significantly inhibited weight gain, improved the metabolic profile of plasma samples, decreased the weights of epididymal WAT (eWAT), inguina WAT (iWAT), and liver, and adipocyte size. Furthermore, rutin also increased the expression of uncoupling protein 1 (Ucp-1) and other thermogenic markers in the WAT and BAT. In 3T3-L1 cells, rutin effectively reduced the formation of lipid droplets, stimulated the expression of thermogenic markers, and reduced the expression of adipogenic genes. Additionally, rutin markedly upregulated the AMP-activated protein kinase (AMPK) pathway, and these effects were diminished by treatment with the AMPK inhibitor compound C (CC). Pretreatment with the calmodulin-dependent protein kinase kinase β (CaMKKβ) inhibitor STO-609 blocked the induction of thermogenic markers in 3T3-L1 cells by rutin. Our results indicated that rutin increased energy consumption, induced WAT "browning" and BAT activation, and thus was a promising target for the development of new therapeutic approaches to improve adipose tissue energy metabolism.
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Affiliation(s)
- Beibei Ma
- Graduate School, Shanxi Medical University, Taiyuan, 030000, Shanxi, PR China
| | - Jinhui Hao
- Department of Clinical Medicine, Fenyang College of Shanxi Medical University, Feiyang, 032200, Shanxi, PR China
| | - Hongmin Xu
- Graduate School, Shanxi Medical University, Taiyuan, 030000, Shanxi, PR China
| | - Li Liu
- Graduate School, Shanxi Medical University, Taiyuan, 030000, Shanxi, PR China
| | - Wendi Wang
- Department of Physiology, Fenyang College of Shanxi Medical University, Feiyang, 032200, Shanxi, PR China
| | - Shizhang Chen
- Department of Medical Laboratory Science, Fenyang College of Shanxi Medical University, Feiyang, 032200, Shanxi, PR China
| | - Huiwen Wu
- Science and Technology Center, Fenyang College of Shanxi Medical University, Feiyang, 032200, Shanxi, PR China
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Matsuzaki S, Mandelbaum RS, Sangara RN, McCarthy LE, Vestal NL, Klar M, Matsushima K, Amaya R, Ouzounian JG, Matsuo K. Trends, characteristics, and outcomes of placenta accreta spectrum: a national study in the United States. Am J Obstet Gynecol 2021; 225:534.e1-534.e38. [PMID: 33894149 DOI: 10.1016/j.ajog.2021.04.233] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/17/2021] [Accepted: 04/07/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although an infrequent occurrence, the placenta can adhere abnormally to the gravid uterus leading to significantly high maternal morbidity and mortality during cesarean delivery. Contemporary national statistics related to a morbidly adherent placenta, referred to as placenta accreta spectrum, are needed. OBJECTIVE This study aimed to examine national trends, characteristics, and perioperative outcomes of women who underwent cesarean delivery for placenta accreta spectrum in the United States. STUDY DESIGN This is a population-based retrospective, observational study querying the National Inpatient Sample. The study cohort included women who underwent cesarean delivery from October 2015 to December 2017 and had a diagnosis of placenta accreta spectrum. The main outcome measures were patient characteristics and surgical outcomes related to placenta accreta spectrum assessed by the generalized estimating equation on multivariable analysis. The temporal trend of placenta accreta spectrum was also assessed by linear segmented regression with log transformation. RESULTS Of 2,727,477 cases who underwent cesarean delivery during the study period, 8030 (0.29%) had the diagnosis of placenta accreta spectrum. Placenta accreta was the most common diagnosis (n=6205, 0.23%), followed by percreta (n=1060, 0.04%) and increta (n=765, 0.03%). The number of placenta accreta spectrum cases increased by 2.1% every quarter year from 0.27% to 0.32% (P=.004). On multivariable analysis, (1) patient demographics (older age, tobacco use, recent diagnosis, higher comorbidity, and use of assisted reproductive technology), (2) pregnancy characteristics (placenta previa, previous cesarean delivery, breech presentation, and grand multiparity), and (3) hospital factors (urban teaching center and large bed capacity hospital) represented the independent characteristics related to placenta accreta spectrum (all, P<.05). The median gestational age at cesarean delivery was 36 weeks for placenta accreta and 34 weeks for both placenta increta and percreta vs 39 weeks for non-placenta accreta spectrum cases (P<.001). On multivariable analysis, cesarean delivery complicated by placenta accreta spectrum was associated with increased risk of any surgical morbidities (78.3% vs 10.6%), Centers for Disease Control and Prevention-defined severe maternal morbidity (60.3% vs 3.1%), hemorrhage (54.1% vs 3.9%), coagulopathy (5.3% vs 0.3%), shock (5.0% vs 0.1%), urinary tract injury (8.3% vs 0.2%), and death (0.25% vs 0.01%) compared with cesarean delivery without placenta accreta spectrum. When further analyzed by subtype, cesarean delivery for placenta increta and percreta was associated with higher likelihood of hysterectomy (0.4% for non-placenta accreta spectrum, 45.8% for accreta, 82.4% for increta, 78.3% for percreta; P<.001) and urinary tract injury (0.2% for non-placenta accreta spectrum, 5.2% for accreta, 11.8% for increta, 24.5% for percreta; P<.001). Moreover, women in the placenta increta and percreta groups had markedly increased risks of surgical mortality compared with those without placenta accreta spectrum (increta, odds ratio, 19.9; and percreta, odds ratio, 32.1). CONCLUSION Patient characteristics and outcomes differ across the placenta accreta spectrum subtypes, and women with placenta increta and percreta have considerably high surgical morbidity and mortality risks. Notably, 1 in 313 women undergoing cesarean delivery had a diagnosis of placenta accreta spectrum by the end of 2017, and the incidence seems to be higher than reported in previous studies.
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Affiliation(s)
- Shinya Matsuzaki
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA
| | - Rachel S Mandelbaum
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA
| | - Rauvynne N Sangara
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA
| | - Lauren E McCarthy
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Nicole L Vestal
- Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Maximilian Klar
- Department of Obstetrics and Gynecology, University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA
| | - Rodolfo Amaya
- Department of Anesthesiology, University of Southern California, Los Angeles, CA
| | - Joseph G Ouzounian
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA; Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA.
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Vestal NL, Sangara RN, Mandelbaum RS, Matsuzaki S, McCarthy LE, Matsushima K, Yoshihara K, Klar M, Lee RH, Ouzounian JG, Matsuo K. Racial and ethnic disparity in characteristics and outcomes of women with placenta accreta spectrum: a comparative study. Reprod Sci 2021; 29:1988-2000. [PMID: 34716538 DOI: 10.1007/s43032-021-00781-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 10/19/2021] [Indexed: 02/05/2023]
Abstract
Placenta accreta spectrum (PAS) refers to the spectrum of diagnoses involving abnormally and morbidly adherent trophoblastic tissue to the gravid uterus. These disorders are associated with significant maternal morbidity and mortality. While race/ethnicity is known to impact pregnancy outcomes, racial disparities have not been previously examined in women with PAS. The objective of current study was to compare patient characteristics and perioperative outcomes of women with PAS who underwent cesarean delivery across race/ethnicity. This is a comparative study that retrospectively queried the National Inpatient Sample, a hospital-based inpatient database in the USA. The study cohort was women diagnosed with PAS who underwent cesarean delivery from 10/2015 to 12/2018. The exposure group was race/ethnicity. Main outcomes were (i) patient/pregnancy characteristics and (ii) surgical morbidity for cesarean delivery, assessed in multivariable analysis. A total of 10,535 women comprised the study cohort (White n = 5,230 [49.6%], Black n = 2,045 [19.4%], Hispanic n = 2,540 [24.1%], and Asian n = 720 [6.8%]). Patient demographics, pregnancy characteristics, and hospital factors for the non-White groups significantly differed compared to the White group. Older age, obesity, diabetes, placenta previa, percreta, non-elective surgery, lower median household income, and Medicaid particularly represented the non-White groups. When perioperative outcomes were compared, non-White women were more likely to have any measured complications, hemorrhage/transfusion, and shock/coagulopathy compared to White women. Various sensitivity analyses redemonstrated the main cohort results. In conclusion, this study suggests that there were significant disparities in patient characteristics and outcomes of women with PAS across race/ethnicity.
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Affiliation(s)
- Nicole L Vestal
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, 2020 Zonal Avenue, IRD 520, Los Angeles, CA, 90033, USA.,Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Rauvynne N Sangara
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, 2020 Zonal Avenue, IRD 520, Los Angeles, CA, 90033, USA
| | - Rachel S Mandelbaum
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, 2020 Zonal Avenue, IRD 520, Los Angeles, CA, 90033, USA
| | - Shinya Matsuzaki
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, 2020 Zonal Avenue, IRD 520, Los Angeles, CA, 90033, USA
| | - Lauren E McCarthy
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, 2020 Zonal Avenue, IRD 520, Los Angeles, CA, 90033, USA.,Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Kosuke Yoshihara
- Department of Obstetrics and Gynecology, Niigata University School of Medicine, Niigata, Japan
| | - Maximilian Klar
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Richard H Lee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Joseph G Ouzounian
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, 2020 Zonal Avenue, IRD 520, Los Angeles, CA, 90033, USA. .,Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA.
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Matsuo K, Matsuzaki S, Vestal NL, Sangara RN, Mandelbaum RS, Matsushima K, Klar M, Ouzounian JG. Utilizations and outcomes of intra-arterial balloon occlusion at cesarean hysterectomy for placenta accreta spectrum. Acta Obstet Gynecol Scand 2021; 100:2234-2243. [PMID: 34622939 DOI: 10.1111/aogs.14266] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/30/2021] [Accepted: 08/31/2021] [Indexed: 01/23/2023]
Abstract
INTRODUCTION This study examined national-level trends, characteristics, and perioperative outcomes of women who had intra-arterial balloon occlusion at cesarean hysterectomy for placenta accreta spectrum (PAS). MATERIAL AND METHODS This was a population-based retrospective observational study that queried the National Inpatient Sample from October 2015 to December 2018. Study population was women who underwent hysterectomy at cesarean delivery for PAS (n = 6440 in 806 centers). Exposure allocation was the use of intra-arterial balloon occlusion. Main outcome measures were (a) characteristics associated with intra-arterial balloon occlusion use, and (b) perioperative outcome including hemorrhage, blood transfusion, coagulopathy, shock, urinary tract injury, intra-arterial balloon occlusion-related complication (arterial injury, arterial thrombosis, and lower extremities ischemia), and death, assessed in multivariable analysis. RESULTS Intra-arterial balloon occlusion was used in 420 (6.5%) women in 64 (7.9%) centers. Utilization of intra-arterial balloon occlusion during cesarean hysterectomy for placenta accreta decreased significantly over time (from 6.3% to 3.1%, p < 0.001), but not in placenta increta (from 12.8% to 9.3%, p = 0.204) or placenta percreta (from 21.3% to 17.5%, p = 0.344). In a multivariable analysis, patient factors (younger age, earlier year, obesity, diabetes mellitus), pregnancy factors (placenta increta/percreta, previous cesarean delivery, placenta previa, and early gestational age), and facility factors (large bed capacity, urban teaching status, and Northeast/West regions) represented the independent characteristics for using the intra-arterial balloon occlusion (all, p < 0.05). In a classification-tree model, the absolute difference in intra-arterial balloon occlusion use among 18 utilization patterns was 48% (range, 0%-48%). In perioperative outcome analysis, women who received intra-arterial balloon occlusion were more likely to have coagulopathy (adjusted odds ratio [aOR] 3.43) and arterial thrombosis (aOR 9.82) in placenta accreta, but less likely to have hemorrhage (aOR 0.25) in placenta increta, and blood transfusion (aOR 0.60) and urinary tract injury (aOR 0.28) in placenta percreta compared with those who did not (all, p < 0.05). CONCLUSIONS There is a wide range in the utilization of intra-arterial balloon occlusion at cesarean hysterectomy for PAS based on patient, pregnancy, and facility factors, which implies that there is a lack of universal practice guidelines in this surgical procedure. Whether the use of intra-arterial balloon occlusion in the severe forms of PAS improves surgical outcome merits further investigation.
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Affiliation(s)
- Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA.,Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Shinya Matsuzaki
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Nicole L Vestal
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Rauvynne N Sangara
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Rachel S Mandelbaum
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Maximilian Klar
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Joseph G Ouzounian
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, CA, USA
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