Use of case fatality and readmission measures to compare hospital performance in gynaecology

Do critical care units play a role in the management of gynaecological oncology patients? The contribution of gynaecologic oncologist in running critical care units

Routine post-operative care in high dependency unit (HDU), surgical intensive care unit (SICU) and intensive care unit (ICU) after high-risk gynaecological oncology surgical procedures may allow for greater recognition and correct management of post-operative complications, thereby reducing long-term morbidity and mortality. On the other hand, unnecessary admissions to these units lead to increased morbidity - nosocomial infections, increased length of hospital stay and higher hospital costs. Gynaecological oncology surgeons continue to look after their patient in the HDU/SICU and have the final role in decision-making on day-to-day basis, making it important to be well versed in critical care management and ensure the best care for their patients. Post-operative monitoring and the presence of comorbid illnesses are the most common reasons for admission to the HDU/SICU. Elderly and malnutritioned patients, as well as, bowel resection, blood loss or greater fluid resuscitation during the surgery have prolonged HDU/SICU stay. Patients with ovarian cancer have a worse survival outcome than the patients with other types of gynaecological cancer. Dependency care is a part of surgical management and it should be incorporated formally into gynaecologic oncology training programme.

Use of computed tomography in the diagnosis of bowel complications after gynecologic surgery

OBJECTIVE

To determine factors predictive of bowel complications after gynecologic surgery and establish the added utility of computed tomography (CT) in the diagnostic process.

METHODS

Patients who underwent gynecologic surgery between January 2, 2008, and December 30, 2010, who had CT scans of the abdomen, pelvis, or abdomen and pelvis within 42 days for a suspected bowel complication were identified. Logistic regression analysis was used to identify factors predictive of bowel-related complications. The diagnostic accuracy of CT was compared among patient risk groups based on clinical suspicion (pretest probability) of bowel complications.

RESULTS

Among 205 eligible patients, 38 (18.5%) patients had a bowel-related complication. Mean time from surgery to CT was 12.4 (10.1) days. Clinical characteristics were used to develop a clinical model that included unexpected drainage from the drain, wound, or stoma (adjusted odds ratio [OR] 26.3, 95% confidence interval [CI] 3.1-224.4, P=.003), coronary artery disease (OR 10.7, CI 1.4-80.9, P=.022), laparotomy (compared with minimally invasive surgery) (OR 4.4, CI 1.1-17.2, P=.032), and age older than 45 years (OR 2.4, CI 0.7-8.8, P=.18). Addition of CT to clinical evaluation increased the predictive ability of the model (area under the curve) from 0.73 to 0.99. Among 57 low-risk patients, three with confirmed bowel-related complications would have been missed if CT was not performed. Among 13 high-risk patients, CT sensitivity was 70%, and it was negative for bowel complications in three patients subsequently confirmed to have serious complications (one anastomotic leak, two bowel perforations).

CONCLUSIONS

In patients who have undergone gynecologic surgery and have a high clinical probability of a postoperative bowel-related complication, CT alone may fail to accurately identify patients with serious complications.

LEVEL OF EVIDENCE

: II.