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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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Pandraklakis A, Haidopoulos D, Lappas T, Stamatakis E, Oikonomou MD, Valsamidis D, Rodolakis A, Thomakos N. Enhanced Recovery After Surgery Protocols in Obese Gynecological Oncology Patients: A Single-Center Experience. Cureus 2023; 15:e40453. [PMID: 37456369 PMCID: PMC10349384 DOI: 10.7759/cureus.40453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2023] [Indexed: 07/18/2023] Open
Abstract
Objective The aim of this study is to present our experience and evaluate the safety and outcomes of the implementation of Enhanced Recovery After Surgery (ERAS) protocols in obese patients who underwent surgery for suspected or confirmed gynecological malignancies. Method From January 2020 to September 2021, 217 patients underwent laparotomy for a confirmed or suspected gynecological malignancy following a 19-element ERAS pathway. The patients were divided into two groups: obese (BMI ≥ 30 kg/m2, n = 104) and non-obese (BMI < 30, n = 113). Both groups were treated with a 19-element ERAS protocol. Results After dividing the 217 patients into two groups, significantly more comorbidities were observed in the obese group (diabetes mellitus: 23% vs. 8%, p = 0.004; ASA score grade 3: 25.0% vs. 6.2%, p < 0.001), as well as higher rates of endometrial cancer (51.9% vs. 17.7%, p < 0.001) compared to the non-obese group. The overall ERAS compliance rates when matched element by element were similar. Postoperatively, complication rates of all grades were significantly higher in the obese group (46.1% vs. 27.4%, p < 0.001) without differences in the length of stay, readmission, and reoperation rates. Conclusion In this retrospective study, we showed that obese gynecological oncology patients can be safely managed with ERAS protocols perioperatively while potentially minimizing the adverse outcomes in these otherwise high-risk patients.
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Affiliation(s)
- Anastasios Pandraklakis
- Division of Gynaecologic Oncology, 1st Department of Obstetrics and Gynaecology, Alexandra Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
| | - Dimitrios Haidopoulos
- Division of Gynaecologic Oncology, 1st Department of Obstetrics and Gynaecology, Alexandra Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
| | - Theodoros Lappas
- Department of Anaesthesiology, Alexandra General Hospital, Athens, GRC
| | | | - Maria D Oikonomou
- The Fertility Centre, Chelsea and Westminster Hospital NHS Foundation Trust, London, GBR
| | | | - Alexandros Rodolakis
- Division of Gynaecologic Oncology, 1st Department of Obstetrics and Gynaecology, Alexandra Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
| | - Nikolaos Thomakos
- Division of Gynaecologic Oncology, 1st Department of Obstetrics and Gynaecology, Alexandra Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
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ERAS implementation in an urban patient population undergoing gynecologic surgery. Best Pract Res Clin Obstet Gynaecol 2022; 85:1-11. [PMID: 36031533 DOI: 10.1016/j.bpobgyn.2022.07.009] [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: 07/22/2022] [Accepted: 07/26/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) protocols improve outcomes. We investigated ERAS implementation in a population with comorbid conditions, inadequate insurance, and barriers to healthcare undergoing gynecologic surgery. OBJECTIVE To investigate ERAS implementation in publicly insured/uninsured patients undergoing gynecologic surgery on hospital length of stay (LOS), 30-day hospital readmission rates, opioid administration, and pain scores. STUDY DESIGN Data were obtained pre- and post-ERAS implementation. Patients undergoing gynecologic surgery with private insurance, public insurance, and uninsured were included (N = 589). LOS, readmission <30 days, opioid administration, and pain scores were assessed. RESULTS Implementation of ERAS led to shorter LOS 1.75 vs. 1.49 days (p = 0.008). Average pain scores decreased from 3.07 pre-ERAS vs. 2.47 post-ERAS (p = <0.001). Opioid use decreased for ERAS patients (67.22 vs. 33.18, p = <0.001). Hospital readmission rates were unchanged from 8.2% pre-ERAS vs. 10.3% post-ERAS (p = 0.392). CONCLUSIONS ERAS decreased pain scores and opioid use without increasing LOS or readmissions.
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Bhardwaj NJ, Chae K, Sheng JY, Yeh HC. Clinical interventions to break the obesity and cancer link: a narrative review. Cancer Metastasis Rev 2022; 41:719-735. [PMID: 35933566 DOI: 10.1007/s10555-022-10055-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 07/25/2022] [Indexed: 11/26/2022]
Abstract
Excess body weight is a significant risk factor for the development and recurrence of many types of cancer. Patients with a history or current diagnosis of cancer who are overweight or have obesity have an increased risk of cancer treatment-related morbidity, recurrence, and decreased quality of life. Weight loss and maintenance of a healthy body weight may reduce cancer morbidity and recurrence in cancer survivors. While guidelines for cancer survivorship elaborate sufficiently on lifestyle interventions, little guidance is provided when considering additional therapies like anti-obesity pharmacotherapy or bariatric surgery for weight loss. This review will highlight and address current recommendations and feasible interventions that clinicians may consider to further reduce the incidence and recurrence of cancer in patients with obesity.
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Affiliation(s)
- Nakul J Bhardwaj
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Kacey Chae
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jennifer Y Sheng
- Department of Oncology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Hsin-Chieh Yeh
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
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Prodromidou A, Koulakmanidis AM, Haidopoulos D, Nelson G, Rodolakis A, Thomakos N. Where Enhanced Recovery after Surgery (ERAS) Protocols Meet the Three Major Current Pandemics: COVID-19, Obesity and Malignancy. Cancers (Basel) 2022; 14:cancers14071660. [PMID: 35406432 PMCID: PMC8996966 DOI: 10.3390/cancers14071660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 01/27/2023] Open
Abstract
Simple Summary The SARS-CoV-2 (COVID-19) pandemic has significantly modified the medical services provided for patients that receive care either for COVID-19 or for those that need care for benign diseases, including obesity, or for malignant ones, such as gynecological cancer. We sought to investigate the association among three major worldwide health issues (COVID-19, obesity, and malignancy) and how ERAS protocols can potentially provide optimal management of patients with obesity and malignancy during the COVID-19 pandemic, with special attention to patients who required surgery for gynecologic oncology. We strongly believe that the application of ERAS protocols could play a key role during these unprecedented COVID-19 times. Abstract The outbreak of the SARS-CoV-2 (COVID-19) pandemic has transformed the provision of medical services for both patients that receive care for COVID-19 and for those that need care either for benign diseases, including obesity, or for malignancies, such as gynecological cancer. In this perspective article, we focus on the association among three major worldwide health issues and how ERAS protocols can potentially provide optimal management of patients with obesity and malignancy during the COVID-19 pandemic, with special attention to patients who required surgery for gynecologic oncology. A thorough search of the literature on the respective topics was performed. Patients with malignancy and obesity presented with increased vulnerability to COVID-19 infection. However, the management of their disease should not be withheld. Protective measures should be established to reduce exposure of patients with oncological diseases to SARS-CoV-2 while simultaneously enabling their access to vaccination. Since ERAS protocols have proved to be efficient in many surgical fields, including gynecologic oncology, general surgery, and orthopedics, we strongly believe that ERAS protocols may play a significant role in this effort. The end of the COVID-19 pandemic cannot be accurately predicted. Nevertheless, we have to ensure the appropriate and efficient management of certain groups of patients.
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Affiliation(s)
- Anastasia Prodromidou
- Gynaecologic Oncology Unit, 1st Department of Obstetrics and Gynaecology, Alexandra Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece; (A.-M.K.); (D.H.); (A.R.); (N.T.)
- Correspondence: ; Tel.: +30-6972751000
| | - Aristotelis-Marios Koulakmanidis
- Gynaecologic Oncology Unit, 1st Department of Obstetrics and Gynaecology, Alexandra Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece; (A.-M.K.); (D.H.); (A.R.); (N.T.)
| | - Dimitrios Haidopoulos
- Gynaecologic Oncology Unit, 1st Department of Obstetrics and Gynaecology, Alexandra Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece; (A.-M.K.); (D.H.); (A.R.); (N.T.)
| | - Gregg Nelson
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, AB T2N 1N4, Canada;
| | - Alexandros Rodolakis
- Gynaecologic Oncology Unit, 1st Department of Obstetrics and Gynaecology, Alexandra Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece; (A.-M.K.); (D.H.); (A.R.); (N.T.)
| | - Nikolaos Thomakos
- Gynaecologic Oncology Unit, 1st Department of Obstetrics and Gynaecology, Alexandra Hospital, National and Kapodistrian University of Athens, 11528 Athens, Greece; (A.-M.K.); (D.H.); (A.R.); (N.T.)
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Boitano TKL, Smith HJ, Cohen AC, Todd A, Leath Iii CA, Straughn JM. An enhanced recovery protocol decreases complication rates in high-risk gynecologic oncology patients undergoing non-emergent laparotomy. Int J Gynecol Cancer 2021; 31:721-726. [PMID: 33495207 DOI: 10.1136/ijgc-2020-002270] [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: 11/20/2020] [Revised: 01/13/2021] [Accepted: 01/14/2021] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Enhanced recovery protocols are now established as the standard of care leading to improved perioperative outcomes and associated cost-benefits. The objective of this study was to evaluate the impact of an enhanced recovery program on complication rates in high-risk gynecologic oncology patients undergoing surgery. METHODS This retrospective cohort study included gynecologic oncology patients with pathology-proven malignancy undergoing non-emergent laparotomy from October 2016 to December 2018 managed on an enhanced recovery protocol, and a control group from October 2015 through September 2016 prior to enhanced recovery protocol implementation. The primary outcome was complication rates in a high-risk population pre- and post-enhanced recovery protocol. High-risk patients were defined as those with obesity (body mass index >30 kg/m2) and/or age ≥65 years. Analysis was performed using Statistical Package for Social Sciences (SPSS) v.24. RESULTS A total of 363 patients met the inclusion criteria: 104 in the control group and 259 in the enhanced recovery protocol group. Patient demographics, including age, body mass index, diagnosis, and performance status, were similar. Overall complication rates were less in the enhanced recovery protocol group (29% vs 53.8%; p<0.0001). The enhanced recovery protocol group had a shorter length-of-stay compared with control (3.3 vs 4.2 days; p<0.0001). The 30-day readmission rates were similar between the groups (9.6% vs 13.5%; p=0.19). In the enhanced recovery protocol group compared with control, complication rates were less in obese patients (29.4% vs 57.8%; p<0.0001), morbidly obese patients (20.9% vs 76.2%; p<0.0001), and age ≥65 (36.1% vs 57.1%; p<0.0001). The most common complications in the enhanced recovery protocol group were ileus (9.7%), pulmonary complications (2.7%), and blood transfusions (10.8%). CONCLUSIONS Implementation of an enhanced recovery protocol decreases complication rates and length-of-stay in morbidly obese and geriatric patients with gynecologic malignancy without an increase in readmission rates.
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Affiliation(s)
- Teresa K L Boitano
- Division of Gynecologic Oncology, Obstetrics and Gynecology, University of Alabama at Birmingham HCOP, Birmingham, Alabama, USA
| | - Haller J Smith
- Division of Gynecologic Oncology, Obstetrics and Gynecology, University of Alabama at Birmingham HCOP, Birmingham, Alabama, USA
| | - Alexander C Cohen
- Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Allison Todd
- Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Charles A Leath Iii
- Division of Gynecologic Oncology, Obstetrics and Gynecology, University of Alabama at Birmingham HCOP, Birmingham, Alabama, USA
| | - J Michael Straughn
- Division of Gynecologic Oncology, Obstetrics and Gynecology, University of Alabama at Birmingham HCOP, Birmingham, Alabama, USA
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