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Zhao L, Li B, Li N, Bao J, Zhu X, Hai K. Evaluation of intraoperative lidocaine on the prevention of postoperative shoulder pain in gynecologic laparoscopy: A prospective randomized, double-blind, placebo-controlled study. J Obstet Gynaecol Res 2024; 50:1902-1908. [PMID: 39231797 DOI: 10.1111/jog.16053] [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: 04/09/2024] [Accepted: 07/31/2024] [Indexed: 09/06/2024]
Abstract
AIM To assess the effectiveness of intraoperative lidocaine in reducing the incidence of post-laparoscopic shoulder pain (PLSP) after gynecologic laparoscopy. METHODS Patients undergoing total laparoscopic hysterectomy were randomly divided into two groups: the lidocaine group, receiving an initial intravenous dose of lidocaine (1.5 mg/kg) before anesthesia induction, followed by a continuous infusion at 2 mg/kg/h, and the placebo group, receiving saline. The primary endpoint was the determination of PLSP incidence over a 72-h period post-surgery. Secondary endpoints included a comprehensive evaluation of pain intensity, as measured by the Numeric Rating Scale (NRS), for shoulder, abdominal, and incisional pain within a 72-hour period postoperatively. Additionally, the endpoints involved the assessment of Lofencodeine or Parexib Sodium usage frequency, incidence of nausea and vomiting, duration of anesthesia and surgical procedure, as well as the duration of hospital stay. RESULTS Our study did not demonstrate any significant benefit in the incidence of PLSP during the postoperative period. PLSP occurred in 14 out of 41 patients (34.1%) in the lidocaine group, compared with 15 out of 41 patients (36.6%) in the placebo group (p = 0.817). Intravenous lidocaine reduced abdominal pain scores and decreased the need for postoperative analgesics within 72 h after surgery. No significant differences were found in incisional and shoulder pain intensity, nausea and vomiting rates, or hospitalization duration between groups. CONCLUSIONS The infusion of lidocaine did not yield a reduction in the incidence or severity of PLSP in patients undergoing laparoscopic total hysterectomy.
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Affiliation(s)
- Liyan Zhao
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Ningxia Medical University, Yinchuan, China
- School of Basic Medicine, Ningxia Medical University, Yinchuan, China
| | - Bin Li
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Ningxia Medical University, Yinchuan, China
| | - Ningkang Li
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Ningxia Medical University, Yinchuan, China
| | - Jiamin Bao
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Ningxia Medical University, Yinchuan, China
| | - Xiaoning Zhu
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Ningxia Medical University, Yinchuan, China
| | - Kerong Hai
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, Ningxia Medical University, Yinchuan, China
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Riviere D, van den Boezem PB, Besselink MG, van Laarhoven CJ, Kooby DA, Vollmer CM, Davidson BR, Gurusamy KS. Minimally invasive versus open pancreatoduodenectomy in benign, premalignant, and malignant disease. Cochrane Database Syst Rev 2024; 7:CD014017. [PMID: 39056402 PMCID: PMC11274036 DOI: 10.1002/14651858.cd014017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2024]
Abstract
OBJECTIVES This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the benefits and harms of laparoscopic or robot-assisted pancreatoduodenectomy versus open pancreatoduodenectomy for people with benign, premalignant, and malignant disease.
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Affiliation(s)
- Deniece Riviere
- Department of Medical Imaging, Radboud University Medical Center Nijmegen, Nijmegen, Netherlands
| | | | - Marc G Besselink
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | | | - David A Kooby
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Charles M Vollmer
- Department of Gastrointestinal Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Brian R Davidson
- Division of Surgery and Interventional Science, University College London, London, UK
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Wu Q, Zhou Y, Sun S, Li H, Cao S, Shou H. Clinical analysis of acute postoperative pain after total laparoscopic hysterectomy for adenomyosis and uterine fibroids - a prospective observational study. Ann Med 2023; 55:2281510. [PMID: 37994446 PMCID: PMC10836289 DOI: 10.1080/07853890.2023.2281510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 11/04/2023] [Indexed: 11/24/2023] Open
Abstract
OBJECTIVE To investigate the outcome of total laparoscopic hysterectomy (TLH) and postoperative pain characteristics and compare the pain severity after TLH for adenomyosis or uterine fibroids. METHODS This prospective observational study collected 101 patients received TLH for adenomyosis (AD group) including 41 patients were injected goserelin (3.6 mg) 28 days before TLH, while other adenomyosis patients received TLH without preoperative treatment, and 113 patients received TLH for uterine fibroids (UF group). Pain scores were evaluated at different time sites from operation day to postoperative 72 h using the numeric rating scale. Clinical data were collected from clinical record. RESULTS Operative time and anaesthetic time were longer in the AD group than those in the UF group (66.88 ± 8.65 vs. 64.46 ± 7.21, p = 0.04; 83.95 ± 10.05 vs. 79.77 ± 6.88, p < 0.01), severe endometriosis was quite more common in AD group (23.76% vs. 2.65%, p < 0.01). Postoperative usage of Flurbiprofen in AD group were more than that of UF group (15.48 ± 38.00 vs. 4.79 ± 18.16, p = 0.02). Total pains and abdominal visceral pains of AD group were more severe compared with UF group in motion and rest pattern at several time sites, while incision pain and shoulder pain were similar. The total postoperative pains after goserelin preoperative treatment in AD group were less than that without goserelin preoperative treatment (p < 0.05). The levels of serum NPY, PGE2 and NGF after laparoscopic hysterectomy of adenomyosis reduced with GnRH agonist pretreatment. CONCLUSIONS Acute postoperative pain for adenomyosis and uterine fibroids showed considerably different severity, postoperative total pain and abdominal visceral pains of TLH for adenomyosis were more severe compared with uterine fibroids. While patients received goserelin before laparoscopic hysterectomy of adenomyosis suffered from less severity of postoperative total pain than that without goserelin preoperative treatment.
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Affiliation(s)
- Qing Wu
- Center for Reproductive Medicine, Department of Gynecology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, China
| | - Yun Zhou
- Department of Obstetrics and Gynecology, Shengli Clinical Medical College of Fujian Medical University and Fujian Provincial Hospital, Fuzhou, China
| | - Saijun Sun
- Tiantai People’s Hospital of Zhejiang Province, Zhejiang, China
| | - Hui Li
- Center for Reproductive Medicine, Department of Gynecology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, China
| | - Shanshan Cao
- Tiantai People’s Hospital of Zhejiang Province, Zhejiang, China
| | - Huafeng Shou
- Center for Reproductive Medicine, Department of Gynecology, Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College), Hangzhou, Zhejiang, China
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Pickett CM, Seeratan DD, Mol BWJ, Nieboer TE, Johnson N, Bonestroo T, Aarts JW. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2023; 8:CD003677. [PMID: 37642285 PMCID: PMC10464658 DOI: 10.1002/14651858.cd003677.pub6] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
BACKGROUND Currently, there are five major approaches to hysterectomy for benign gynaecological disease: abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH), robotic-assisted hysterectomy (RH) and vaginal natural orifice hysterectomy (V-NOTES). Within the LH category we further differentiate the laparoscopic-assisted vaginal hysterectomy (LAVH) from the total laparoscopic hysterectomy (TLH) and single-port laparoscopic hysterectomy (SP-LH). OBJECTIVES To assess the effectiveness and safety of different surgical approaches to hysterectomy for women with benign gynaecological conditions. SEARCH METHODS We searched the following databases (from their inception to December 2022): the Cochrane Gynaecology and Fertility Specialised Register of Controlled Trials, CENTRAL, MEDLINE, Embase, CINAHL and PsycINFO. We also searched the trial registries and relevant reference lists, and communicated with experts in the field for any additional trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) in which clinical outcomes were compared between one surgical approach to hysterectomy and another. DATA COLLECTION AND ANALYSIS At least two review authors independently selected trials, assessed risk of bias and performed data extraction. Our primary outcomes were return to normal activities, satisfaction and quality of life, intraoperative visceral injury and major long-term complications (i.e. fistula, pelvic-abdominal pain, urinary dysfunction, bowel dysfunction, pelvic floor condition and sexual dysfunction). MAIN RESULTS We included 63 studies with 6811 women. The evidence for most comparisons was of low or moderate certainty. The main limitations were poor reporting and imprecision. Vaginal hysterectomy (VH) versus abdominal hysterectomy (AH) (12 RCTs, 1046 women) Return to normal activities was probably faster in the VH group (mean difference (MD) -10.91 days, 95% confidence interval (CI) -17.95 to -3.87; 4 RCTs, 274 women; I2 = 67%; moderate-certainty evidence). This suggests that if the return to normal activities after AH is assumed to be 42 days, then after VH it would be between 24 and 38 days. We are uncertain whether there is a difference between the groups for the other primary outcomes. Laparoscopic hysterectomy (LH) versus AH (28 RCTs, 3431 women) Return to normal activities may be sooner in the LH group (MD -13.01 days, 95% CI -16.47 to -9.56; 7 RCTs, 618 women; I2 = 68%, low-certainty evidence), but there may be more urinary tract injuries in the LH group (odds ratio (OR) 2.16, 95% CI 1.19 to 3.93; 18 RCTs, 2594 women; I2 = 0%; moderate-certainty evidence). This suggests that if the return to normal activities after abdominal hysterectomy is assumed to be 37 days, then after laparoscopic hysterectomy it would be between 22 and 25 days. It also suggests that if the rate of ureter injury during abdominal hysterectomy is assumed to be 0.2%, then during laparoscopic hysterectomy it would be between 0.2% and 2%. We are uncertain whether there is a difference between the groups for the other primary outcomes. LH versus VH (22 RCTs, 2135 women) We are uncertain whether there is a difference between the groups for any of our primary outcomes. Both short- and long-term complications were rare in both groups. Robotic-assisted hysterectomy (RH) versus LH (three RCTs, 296 women) None of the studies reported satisfaction rates or quality of life. We are uncertain whether there is a difference between the groups for our other primary outcomes. Single-port laparoscopic hysterectomy (SP-LH) versus LH (seven RCTs, 621 women) None of the studies reported satisfaction rates, quality of life or major long-term complications. We are uncertain whether there is a difference between the groups for rates of intraoperative visceral injury. Total laparoscopic hysterectomy (TLH) versus laparoscopic-assisted vaginal hysterectomy (LAVH) (three RCTs, 233 women) None of the studies reported satisfaction rates or quality of life. We are uncertain whether there is a difference between the groups for rates of intraoperative visceral injury or major long-term complications. Transvaginal natural orifice transluminal endoscopic surgery (V-NOTES) versus LH (two RCTs, 96 women) We are uncertain whether there is a difference between the groups for rates of bladder injury. Our other primary outcomes were not reported. Overall, adverse events were rare in the included studies. AUTHORS' CONCLUSIONS Among women undergoing hysterectomy for benign disease, VH appears to be superior to AH. When technically feasible, VH should be performed in preference to AH because it is associated with faster return to normal activities, fewer wound/abdominal wall infections and shorter hospital stay. Where VH is not possible, LH has advantages over AH including faster return to normal activities, shorter hospital stay, and decreased risk of wound/abdominal wall infection, febrile episodes or unspecified infection, and transfusion. These advantages must be balanced against the increased risk of ureteric injury and longer operative time. When compared to LH, VH was associated with no difference in time to return to normal activities but shorter operative time and shorter hospital stay. RH and V-NOTES require further evaluation since there is a lack of evidence of any patient benefit over conventional LH. Overall, the evidence in this review has to be interpreted with caution as adverse event rates were low, resulting in low power for these comparisons. The surgical approach to hysterectomy should be discussed with the patient and decided in the light of the relative benefits and hazards. Surgical expertise is difficult to quantify and poorly reported in the available studies and this may influence outcomes in ways that cannot be accounted for in this review. In conclusion, when VH is not feasible, LH has multiple advantages over AH, but at the cost of more ureteric injuries. Evidence is limited for RH and V-NOTES.
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Affiliation(s)
- Charlotte M Pickett
- Department of Obstetrics and Gynecology, University of California San Diego, La Jolla, California, USA
| | - Dachel D Seeratan
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Ben Willem J Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia
| | | | - Neil Johnson
- Obstetrics & Gynaecology, College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Tijmen Bonestroo
- Department of Obstetrics and Gynecology, Rijnstate Hospital, Arnhem, Netherlands
| | - Johanna Wm Aarts
- Obstetrics and Gynaecology, Amsterdam University Medical Centers, Amsterdam, Netherlands
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Kokka F, Bryant A, Olaitan A, Brockbank E, Powell M, Oram D. Hysterectomy with radiotherapy or chemotherapy or both for women with locally advanced cervical cancer. Cochrane Database Syst Rev 2022; 8:CD010260. [PMID: 35994243 PMCID: PMC9394583 DOI: 10.1002/14651858.cd010260.pub3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND This is an update of the Cochrane Review published in Issue 4, 2015. Cervical cancer is one of the most frequent cause of death from gynaecological cancers worldwide. Many new cervical cancer cases in low-income countries present at an advanced stage. Standard care in Europe and the US for locally advanced cervical cancer (LACC) is chemoradiotherapy. In low-income countries, with limited access to radiotherapy, LACC may be treated with chemotherapy and hysterectomy. It is not certain if this improves survival. It is important to assess the value of hysterectomy with radiotherapy or chemotherapy, or both, as an alternative. OBJECTIVES To determine whether hysterectomy, in addition to standard treatment with radiotherapy or chemotherapy, or both, in women with LACC (Stage IB2 to III) is safe and effective compared with standard treatment alone. SEARCH METHODS We searched CENTRAL, MEDLINE via Ovid, Embase via Ovid, LILACS, trial registries and the grey literature up to 3 February 2022. SELECTION CRITERIA We searched for randomised controlled trials (RCTs) that compared treatments involving hysterectomy versus radiotherapy or chemotherapy, or both, in women with LACC International Federation of Gynecology and Obstetrics (FIGO) Stages IB2 to III. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We independently assessed study eligibility, extracted data and assessed the risk of bias. Where possible, we synthesised overall (OS) and progression-free (PFS) or disease-free (DFS) survival in a meta-analysis using a random-effects model. Adverse events (AEs) were incompletely reported and we described the results of single trials in narrative form. We used the GRADE approach to assess the certainty of the evidence. MAIN RESULTS From the searches we identified 968 studies. After deduplication, title and abstract screening, and full-text assessment, we included 11 RCTs (2683 women) of varying methodological quality. This update identified four new RCTs and three ongoing RCTs. The included studies compared: hysterectomy (simple or radical) with radiotherapy or chemoradiotherapy or neoadjuvant chemotherapy (NACT) versus radiotherapy alone or chemoradiotherapy (CCRT) alone or CCRT and brachytherapy. There is also one ongoing study comparing three groups: hysterectomy with CCRT versus hysterectomy with NACT versus CCRT. There were two comparison groups for which we were able to do a meta-analysis. Hysterectomy (radical) with neoadjuvant chemotherapy versus chemoradiotherapy alone Two RCTs with similar design characteristics (620 and 633 participants) found no difference in five-year OS between NACT with hysterectomy versus CCRT. Meta-analysis assessing 1253 participants found no evidence of a difference in risk of death (OS) between women who received NACT plus hysterectomy and those who received CCRT alone (HR 0.94, 95% CI 0.76 to 1.16; moderate-certainty evidence). In both studies, the five-year DFS in the NACT plus surgery group was worse (57%) compared with the CCRT group (65.6%), mostly for Stage IIB. Results of single trials reported no apparent difference in long-term severe complications, grade 3 acute toxicity and severe late toxicity between groups (very low-quality evidence). Hysterectomy (simple or radical) with neoadjuvant chemotherapy versus radiotherapy alone Meta-analysis of three trials of NACT with hysterectomy versus radiotherapy alone, assessing 571 participants, found that women who received NACT plus hysterectomy had less risk of death (OS) than those who received radiotherapy alone (HR 0.71, 95% CI 0.55 to 0.93; I2 = 0%; moderate-quality evidence). However, a significant number of participants who received NACT plus hysterectomy also had radiotherapy. There was no difference in the proportion of women with disease progression or recurrence (DFS and PFS) between NACT plus hysterectomy and radiotherapy groups (RR 0.75, 95% CI 0.53 to 1.05; I2 = 20%; moderate-quality evidence). The certainty of the evidence was low or very-low for all other comparisons for all outcomes. None of the trials reported quality of life outcomes. AUTHORS' CONCLUSIONS From the available RCTs, we found insufficient evidence that hysterectomy with radiotherapy, with or without chemotherapy, improves the survival of women with LACC who are treated with radiotherapy or CCRT alone. The overall certainty of the evidence was variable across the different outcomes and was universally downgraded due to concerns about risk of bias. The certainty of the evidence for NACT and radical hysterectomy versus radiotherapy alone for survival outcomes was moderate. The same occurred for the comparison involving NACT and hysterectomy compared with CCRT alone. Evidence from other comparisons was generally sparse and of low or very low-certainty. This was mainly based on poor reporting and sparseness of data where results were based on single trials. More trials assessing medical management with and without hysterectomy may test the robustness of the findings of this review as further research is likely to have an important impact on our confidence in the estimate of effect.
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Affiliation(s)
- Fani Kokka
- East Kent Gynaecological Oncology Centre, Queen Elizabeth The Queen Mother Hospital, Margate, UK
| | - Andrew Bryant
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Adeola Olaitan
- Department of Gynaecological Oncology, University College London, London, UK
| | - Elly Brockbank
- Department of Gynaecological Oncology, St Bartholomew's Hospital, London, UK
| | - Melanie Powell
- Department of Clinical Oncology, St Bartholomew's Hospital, London, UK
| | - David Oram
- Department of Gynaecological Oncology, St. Bartholomew's Hospital, London, UK
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Total Hysterectomy by Low-Impact Laparoscopy to Decrease Opioids Consumption: A Prospective Cohort Study. J Clin Med 2022; 11:jcm11082165. [PMID: 35456257 PMCID: PMC9030666 DOI: 10.3390/jcm11082165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/05/2022] [Accepted: 04/11/2022] [Indexed: 11/16/2022] Open
Abstract
Our objective was to evaluate postoperative pain and opioid consumption in patients undergoing hysterectomy by low-impact laparoscopy and compare these parameters with conventional laparoscopy. We conducted a prospective study in two French gynecological surgery departments from May 2017 to January 2018. The primary endpoint was the intensity of postoperative pain evaluated by a validated numeric rating scale (NRS) and opioid consumption in the postoperative recovery unit on Day 0 and Day 1. Thirty-two patients underwent low-impact laparoscopy and 77 had conventional laparoscopy. Most of the patients (90.6%) who underwent low-impact laparoscopy were managed as outpatients. There was a significantly higher consumption of strong opioids in the conventional compared to the low-impact group on both Day 0 and Day 1: 26.0% and 36.4% vs. 3.1% and 12.5%, respectively (p = 0.02 and p < 0.01). Over two-thirds of the patients in the low-impact group did not require opioids postoperatively. Two factors were predictive of lower postoperative opioid consumption: low-impact laparoscopy (OR 1.38, 95%CI 1.13−1.69, p = 0.002) and a mean intraoperative peritoneum below 10 mmHg (OR 1.25, 95%CI 1.03−1.51). Total hysterectomy by low-impact laparoscopy is feasible in an outpatient setting and is associated with a marked decrease in opioid consumption compared to conventional laparoscopy.
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Yang J, Fan X, Gao J, Li D, Xu Y, Chen G. Cost effectiveness analysis of total laparoscopic hysterectomy versus total abdominal hysterectomy for uterine fibroids in Western China: a societal perspective. BMC Health Serv Res 2022; 22:252. [PMID: 35209891 PMCID: PMC8867663 DOI: 10.1186/s12913-022-07644-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 02/15/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND As a common female pelvic tumor, uterine fibroids remain the leading cause for hysterectomy in China. Hysterectomy provides a good surgical treatment of uterine fibroids, and it guarantees the removal of all uterine fibroids without lower risk of recurrence. This study compares the cost effectiveness of total laparoscopic hysterectomy (TLH) versus total abdominal hysterectomy (TAH) for women with uterine fibroids from a societal perspective. METHODS An economic analysis was conducted in 392 patients (TLH n = 75; TAH n = 317), including all relevant costs over a 12-month time horizon. Primary outcome was major surgical complications; secondary outcomes were postoperative discomfort symptoms and time of return to normal activities. Clinical, outcomes and costs data were collected from medical records, telephone survey and financial information system. Generalized linear models were used to assess costs and outcomes differences between the two groups. Incremental cost effectiveness ratio (ICER) was used to estimate the cost effectiveness. RESULTS Mean direct costs were $2,925.71 for TLH, $2,436.24 for TAH, respectively. Mean indirect costs were $1,133.22 for TLH, $1,394.85 for TAH, respectively. Incremental societal costs were $256.86 (95%CI: 249.03-264.69). Mean differences in outcome were: 4.53% (95%CI: 4.35-4.71) for major surgical complications; 6.75% (95%CI: 6.45-7.05) for postoperative discomfort symptoms; 1.27 (95%CI: 1.23-1.30) weeks for time to return to normal activities. ICER of TLH was $5,669.16 (95%CI: 5,384.76-5,955.56) per complication averted, $3,801.54 (95%CI: 3,634.81-3,968.28) per postoperative discomfort symptoms averted and $202.96 (95%CI: 194.97-210.95) per week saved to return to normal activities. CONCLUSIONS TLH is cost effective compared with TAH in preventing additional complications based on our estimated conservative threshold in China. The findings provide useful information for researchers to conduct further cost effectiveness analysis based on prospective study which can provide stronger and more evidence, in China. In addition, the data may be useful for Chinese health care policy-makers and medical insurance payers to make related health care decisions.
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Affiliation(s)
- Jinjuan Yang
- School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, 710061, People's Republic of China
| | - Xiaojing Fan
- School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, 710049, People's Republic of China.
| | - Jianmin Gao
- School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, 710049, People's Republic of China.
| | - Dan Li
- School of Public Management, Northwest University School, Xi'an, 710127, People's Republic of China
| | - Yongjian Xu
- School of Public Policy and Administration, Xi'an Jiaotong University, Xi'an, 710049, People's Republic of China
| | - Gang Chen
- Monash Business School, Monash University, Clayton, VIC, 3145, Australia
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Dumont S, Van Trappen P. The clinical and financial impact of introducing robotic-assisted hysterectomy in a tertiary referral centre: A direct cost analysis of consecutive hysterectomies during a decade. Int J Med Robot 2021; 18:e2343. [PMID: 34655461 DOI: 10.1002/rcs.2343] [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: 07/20/2021] [Revised: 09/16/2021] [Accepted: 10/15/2021] [Indexed: 11/11/2022]
Abstract
BACKGROUND Economic data and the clinical impact of introducing robotic-assisted hysterectomy in a European setting are scarce with conflicting findings. METHODS In this retrospective cohort study, the cost and complication rate of the different approaches of hysterectomy are investigated, both benign and (pre)malignant indications were included. RESULTS 844 patients were included: 323 (38.3%) patients underwent robotic-assisted hysterectomy (RAH), 317 (37.5%) total abdominal hysterectomy (TAH), and 204 (24.2%) total laparoscopic hysterectomy (TLH). TAH dropped from 67.2% to 25.5% of procedures, whilst RAH rose to 41.8% of cases. The total hospitalisation cost was for RAH €5208.39 (±€916.91), for TAH €5846.61 (±€4464.37) and for TLH €3790.06 (±€1267.05). The postoperative complication rate of TAH (9.1%) was significantly higher in comparison with TLH and RAH (5.4% and 3.1%, respectively, p = 0.005). CONCLUSIONS RAH has replaced TAH in most cases, especially for large uteri, early-stage endometrial cancer and in selected endometriosis cases, resulting in reduced morbidity with lower hospitalisation costs. The indications for TLH remained, including menorrhagia, adenomyosis and persistent cervical dysplasia.
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Affiliation(s)
- Sander Dumont
- Department of Gynecology and Gynecological Oncology, AZ Sint-Jan Brugge-Oostende AV, Brugge, Belgium.,Department of Gynecology and Obstetrics, University Hospitals Leuven, Leuven, Belgium
| | - Philippe Van Trappen
- Department of Gynecology and Gynecological Oncology, AZ Sint-Jan Brugge-Oostende AV, Brugge, Belgium
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Radtke S, Umeh R, Chavez M, Curiel Z, Mendez K. Utilizing Telemedicine for Delivery of Postoperative Care Following Minimally Invasive Gynecologic Surgery: A Randomized Controlled Trial. Gynecol Minim Invasive Ther 2021; 10:148-153. [PMID: 34485058 PMCID: PMC8384027 DOI: 10.4103/gmit.gmit_66_20] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 10/22/2020] [Accepted: 01/21/2021] [Indexed: 11/18/2022] Open
Abstract
Objectives: Determine if patient satisfaction is greater after delivering postoperative care via telemedicine following minimally invasive gynecologic surgery. Materials and Methods: University-based outpatient clinic; Randomized controlled trial (Canadian Task Force classification I). Females between 18 and 60 years of age scheduled to undergo laparoscopic hysterectomy or laparoscopic excision of endometriosis were invited to participate. Eligible patients were randomized to receive postoperative care either through a traditional office visit or via telemedicine. PSQ-18 satisfaction surveys were performed by phone after the visit. Results: Forty-one patients were analyzed out of which 25 were in the office group and 16 in the telemedicine group. Groups were homogenous to age (41.4 vs. 43.3 p. 48), body mass index (31.9 vs. 30.6 P = 0.52), distance in miles from home (12.7 vs. 12.4 P = 0.92), and parity (P = 0.51). PSQ-18 questionnaire was scored and each category was compared between the office and telemedicine groups. When comparing medians (interquartile range), the general satisfaction and time spent with doctor categories were significantly higher in the telemedicine group (4.0 [4.0, 4.5] vs. 4.5 [4.5, 5.0] P = 0.05), (4.0 [4.0, 4.5] vs. 4.5 [4.0, 5.0] P = 0.05). The remainder of the categories analyzed were not different between groups Technical Quality (4.0 [3.8, 4.5] vs. 4.5 [3.9, 5.0] P = 0.13), Interpersonal Manner (4.0 [4.0, 4.5] vs. 4.5 [4.0, 5.0] P = 0.34), Communication (4.5 [4.0, 4.5] vs. 4.5 [4.3, 5.0] P = 0.21), Accessibility and Convenience (4.0 [3.5, 4.5] v 4.0 [3.6, 4.5] P = 0.84). A chart review was performed, examining the first 30 days after surgery. One (4%) patient in the office group went to the ER after postoperative visit, and 0 in the telemedicine group (P = 0.42). Conclusion: Postoperative care via telemedicine after gynecologic surgery results in higher patient satisfaction.
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Affiliation(s)
- Steven Radtke
- Department of Obstetrics and Gynecology, Texas Tech University Health and Sciences Center, El Paso, Texas, USA
| | - Randle Umeh
- Department of Obstetrics and Gynecology, Texas Tech University Health and Sciences Center, El Paso, Texas, USA
| | - Martha Chavez
- Department of Obstetrics and Gynecology, Texas Tech University Health and Sciences Center, El Paso, Texas, USA
| | - Zuleika Curiel
- Department of Obstetrics and Gynecology, Texas Tech University Health and Sciences Center, El Paso, Texas, USA
| | - Karla Mendez
- Department of Obstetrics and Gynecology, Texas Tech University Health and Sciences Center, El Paso, Texas, USA
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Fetoscopic compared with open repair of myelomeningocele: a 2-delivery cost-effectiveness analysis. Am J Obstet Gynecol MFM 2021; 3:100434. [PMID: 34217856 DOI: 10.1016/j.ajogmf.2021.100434] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/10/2021] [Accepted: 06/23/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Recent studies have compared maternal and neonatal outcomes associated with fetoscopic surgical approach for repair of myelomeningocele compared with an open approach. OBJECTIVE In this study, we compared the cost-effectiveness of these techniques in the setting of a woman seeking future pregnancies. STUDY DESIGN A decision-analytical model using TreeAge software was designed to compare the costs and outcomes of fetoscopic vs open repair in patients with prenatally diagnosed myelomeningocele. We assumed a theoretical cohort of 500 women with a pregnancy affected by myelomeningocele planning to have a future pregnancy. Our model accounted for costs and quality-adjusted life years of the woman, the neonate with myelomeningocele, and the neonate in a subsequent pregnancy. Neonatal outcomes from the incident pregnancy included motor function >2 levels better than the anatomic level, motor function <2 levels better than the anatomic level, and same motor function as the anatomic level, preterm birth in the index pregnancy, neonatal death in the index pregnancy, and major neurodevelopmental disability as a result of preterm birth in the index pregnancy. Neonatal outcomes in the subsequent pregnancy included stillbirth, preterm birth, and neonatal and major neurodevelopmental disability as a result of preterm birth. Probabilities were derived from the literature, and we used a willingness-to-pay threshold of $100,000 per quality-adjusted life year. RESULTS In the index pregnancy, fetoscopic surgical technique resulted in 140 fewer cases of preterm birth and fewer cases of neurodevelopmental disability and neonatal death. Fetoscopic technique resulted in 130 more cases of functional level >2 levels better than the anatomic level, 35 fewer cases of functional level >2 levels worse than the anatomic level, and 107 fewer cases of function same as the anatomic level. In the subsequent pregnancy, fetoscopic surgery led to 22 fewer cases of delivery complications (uterine dehiscence, uterine rupture, and excessive bleeding), 24 fewer cases of stillbirth, and 22 fewer cases of preterm birth. Although the fetoscopic approach was more costly, it was cost-effective with an incremental cost-effectiveness ratio of $1029 per quality-adjusted life year in our theoretical cohort of 500 patients. Monte Carlo probabilistic sensitivity analysis showed that fetoscopic technique is cost-effective 100% of the time. CONCLUSION In our theoretical cohort, the fetoscopic approach was more costly, but resulted in improved outcomes when a subsequent pregnancy was considered.
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Duangpirom W, Pattanaprateep O, Vallibhakara O, Hongsakorn W, Sophonsritsuk A. Cost-Utility Analysis of Total Abdominal Versus Total Laparoscopic Hysterectomy in a Thai University Hospital. J Gynecol Surg 2021. [DOI: 10.1089/gyn.2020.0108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Warat Duangpirom
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Ramathidodi Hospital, Mahidol University, Bangkok, Thailand
| | - Oraluck Pattanaprateep
- Section for Clinical Epidemiology and Biostatistics, and Faculty of Medicine, Ramathidodi Hospital, Mahidol University, Bangkok, Thailand
| | - Orawin Vallibhakara
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Ramathidodi Hospital, Mahidol University, Bangkok, Thailand
- Reproductive Endocrinology and Infertility Unit, Faculty of Medicine, Ramathidodi Hospital, Mahidol University, Bangkok, Thailand
| | - Woradej Hongsakorn
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Ramathidodi Hospital, Mahidol University, Bangkok, Thailand
- Reproductive Endocrinology and Infertility Unit, Faculty of Medicine, Ramathidodi Hospital, Mahidol University, Bangkok, Thailand
| | - Areepan Sophonsritsuk
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Ramathidodi Hospital, Mahidol University, Bangkok, Thailand
- Reproductive Endocrinology and Infertility Unit, Faculty of Medicine, Ramathidodi Hospital, Mahidol University, Bangkok, Thailand
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Google searches and medical publication trends since the 2014 US Food and Drug Administration position on power morcellation: Do these translate into patient awareness? Eur J Obstet Gynecol Reprod Biol 2019; 243:168-172. [PMID: 31715456 DOI: 10.1016/j.ejogrb.2019.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 09/26/2019] [Accepted: 10/13/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Our primary objective was to assess patient awareness by observing Google Trends comparing search terms used in relation to morcellation rather than morcellation alone. Our secondary objective was to review trends and locations of publications on leiomyosarcoma and morcellation following the US Food and Drug Administration (FDA) position statement. STUDY DESIGN To assess Internet trends, we obtained the relative search volume (RSV) for each month from 1 January 2004 to 1 March 2019 from Google Trends using the terms 'fibroid', 'morcellation', and 'fibroid cancer'. RSV ranges from 0 to 100 with 100 being peak popularity for the term, and all other monthly search activity relative to the peak. To assess academic trends, we performed a systematic review of published literature discussing fibroid morcellation within the same time period. We used a two-way independent t-test to compare median RSV, and chi-squared test to compare academic output. P < 0.05 was considered statistically significant. RESULTS Search volume for 'morcellation' peaked during the FDA statement (RSV 0.5 to 2.9, t = 17.5, p < 0.05) but was not sustained. There is an increase in 'fibroid' activity post-FDA statement (RSV 68.8 to 76.3, t = 3.9, p < 0.05). 'Fibroid cancer' remained static throughout (t = 1.5, p = 0.1 and t=-0.5, p = 0.6). Afro-Caribbean countries had the highest RSV for 'fibroid', whereas 'morcellation' RSV was highest in predominantly Western countries. There was a significant increase in the rate of papers published on the subject following the FDA statement (6.8 vs 55.6 papers per year, 95% CI -53.96 to -43.64, p < 0.0001). No academic papers on morcellation were published from countries with the highest RSV for 'fibroid'. CONCLUSION Our study suggests that interest in uterine fibroids has increased since the FDA statement, but the public are perhaps unaware or not concerned of the consequent potential risk of leiomyosarcoma following morcellation. Countries where fibroid interest is highest are not necessarily those that can offer power morcellation. Further studies are required to address how the Internet influences patient choice and informed consent, and how medical professionals can use it to further educate patients on the risks and benefits of laparoscopic myomectomy and power morcellation.
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Lirk P, Thiry J, Bonnet MP, Joshi GP, Bonnet F. Pain management after laparoscopic hysterectomy: systematic review of literature and PROSPECT recommendations. Reg Anesth Pain Med 2019; 44:425-436. [DOI: 10.1136/rapm-2018-100024] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 12/23/2018] [Accepted: 12/31/2018] [Indexed: 11/03/2022]
Abstract
Background and objectivesLaparoscopic hysterectomy is increasingly performed because it is associated with less postoperative pain and earlier recovery as compared with open abdominal hysterectomy. The aim of this systematic review was to evaluate the available literature regarding the management of pain after laparoscopic hysterectomy.Strategy and selection criteriaRandomized controlled trials evaluating postoperative pain after laparoscopic hysterectomy published between January 1996 and May 2018 were retrieved, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, from the EMBASE and MEDLINE databases and the Cochrane Register of Controlled Trials. Efficacy and adverse effects of analgesic techniques were assessed.ResultsOf the 281 studies initially identified, 56 were included. Of these, 31 assessed analgesic or anesthetic interventions and 25 assessed surgical interventions. Acetaminophen, non-steroidal anti-inflammatory drugs, and dexamethasone reduced opioid consumption. Limited evidence hindered recommendations on alpha-2-agonists. Inconsistent evidence was found in the studies investigating pregabalin and transversus abdominis plane block, and no evidence was found for intraperitoneal local anesthetics, port site infiltration, or single-port laparoscopy. Measures to lower peritoneal insufflation pressure or humidify or heat insufflated gas seem to reduce the incidence of shoulder pain, but not abdominal pain.ConclusionsThe baseline analgesic regimen for laparoscopic hysterectomy should include acetaminophen, a non-steroidal anti-inflammatory drug, dexamethasone, and opioids as rescue analgesics.
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Abstract
BACKGROUND Laparoscopy is a common procedure in many surgical specialties. Complications arising from laparoscopy are often related to initial entry into the abdomen. Life-threatening complications include injury to viscera (e.g. bowel, bladder) or to vasculature (e.g. major abdominal and anterior abdominal wall vessels). No clear consensus has been reached as to the optimal method of laparoscopic entry into the peritoneal cavity. OBJECTIVES To evaluate the benefits and risks of different laparoscopic entry techniques in gynaecological and non-gynaecological surgery. SEARCH METHODS We searched the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, and trials registers in January 2018. We also checked the references of articles retrieved. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared one laparoscopic entry technique versus another. Primary outcomes were major complications including mortality, vascular injury of major vessels and abdominal wall vessels, visceral injury of bladder or bowel, gas embolism, solid organ injury, and failed entry (inability to access the peritoneal cavity). Secondary outcomes were extraperitoneal insufflation, trocar site bleeding, trocar site infection, incisional hernia, omentum injury, and uterine bleeding. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, assessed risk of bias, and extracted data. We expressed findings as Peto odds ratios (Peto ORs) with 95% confidence intervals (CIs). We assessed statistical heterogeneity using the I² statistic. We assessed the overall quality of evidence for the main comparisons using GRADE methods. MAIN RESULTS The review included 57 RCTs including four multi-arm trials, with a total of 9865 participants, and evaluated 25 different laparoscopic entry techniques. Most studies selected low-risk patients, and many studies excluded patients with high body mass index (BMI) and previous abdominal surgery. Researchers did not find evidence of differences in major vascular or visceral complications, as would be anticipated given that event rates were very low and sample sizes were far too small to identify plausible differences in rare but serious adverse events.Open-entry versus closed-entryTen RCTs investigating Veress needle entry reported vascular injury as an outcome. There was a total of 1086 participants and 10 events of vascular injury were reported. Four RCTs looking at open entry technique reported vascular injury as an outcome. There was a total of 376 participants and 0 events of vascular injury were reported. This was not a direct comparison. In the direct comparison of Veress needle and Open-entry technique, there was insufficient evidence to determine whether there was a difference in rates of vascular injury (Peto OR 0.14, 95% CI 0.00 to 6.82; 4 RCTs; n = 915; I² = N/A, very low-quality evidence). Evidence was insufficient to show whether there were differences between groups for visceral injury (Peto OR 0.61, 95% CI 0.06 to 6.08; 4 RCTs; n = 915: I² = 0%; very low-quality evidence), or failed entry (Peto OR 0.45, 95% CI 0.14 to 1.42; 3 RCTs; n = 865; I² = 63%; very low-quality evidence). Two studies reported mortality with no events in either group. No studies reported gas embolism or solid organ injury.Direct trocar versus Veress needle entryTrial results show a reduction in failed entry into the abdomen with the use of a direct trocar in comparison with Veress needle entry (OR 0.24, 95% CI 0.17 to 0.34; 8 RCTs; N = 3185; I² = 45%; moderate-quality evidence). Evidence was insufficient to show whether there were differences between groups in rates of vascular injury (Peto OR 0.59, 95% CI 0.18 to 1.96; 6 RCTs; n = 1603; I² = 75%; very low-quality evidence), visceral injury (Peto OR 2.02, 95% CI 0.21 to 19.42; 5 RCTs; n = 1519; I² = 25%; very low-quality evidence), or solid organ injury (Peto OR 0.58, 95% Cl 0.06 to 5.65; 3 RCTs; n = 1079; I² = 61%; very low-quality evidence). Four studies reported mortality with no events in either group. Two studies reported gas embolism, with no events in either group.Direct vision entry versus Veress needle entryEvidence was insufficient to show whether there were differences between groups in rates of vascular injury (Peto OR 0.39, 95% CI 0.05 to 2.85; 1 RCT; n = 186; very low-quality evidence) or visceral injury (Peto OR 0.15, 95% CI 0.01 to 2.34; 2 RCTs; n = 380; I² = N/A; very low-quality evidence). Trials did not report our other primary outcomes.Direct vision entry versus open entryEvidence was insufficient to show whether there were differences between groups in rates of visceral injury (Peto OR 0.13, 95% CI 0.00 to 6.50; 2 RCTs; n = 392; I² = N/A; very low-quality evidence), solid organ injury (Peto OR 6.16, 95% CI 0.12 to 316.67; 1 RCT; n = 60; very low-quality evidence), or failed entry (Peto OR 0.40, 95% CI 0.04 to 4.09; 1 RCT; n = 60; very low-quality evidence). Two studies reported vascular injury with no events in either arm. Trials did not report our other primary outcomes.Radially expanding (STEP) trocars versus non-expanding trocarsEvidence was insufficient to show whether there were differences between groups in rates of vascular injury (Peto OR 0.24, 95% Cl 0.05 to 1.21; 2 RCTs; n = 331; I² = 0%; very low-quality evidence), visceral injury (Peto OR 0.13, 95% CI 0.00 to 6.37; 2 RCTs; n = 331; very low-quality evidence), or solid organ injury (Peto OR 1.05, 95% CI 0.07 to 16.91; 1 RCT; n = 244; very low-quality evidence). Trials did not report our other primary outcomes.Other studies compared a wide variety of other laparoscopic entry techniques, but all evidence was of very low quality and evidence was insufficient to support the use of one technique over another. AUTHORS' CONCLUSIONS Overall, evidence was insufficient to support the use of one laparoscopic entry technique over another. Researchers noted an advantage of direct trocar entry over Veress needle entry for failed entry. Most evidence was of very low quality; the main limitations were imprecision (due to small sample sizes and very low event rates) and risk of bias associated with poor reporting of study methods.
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Affiliation(s)
- Gaity Ahmad
- Pennine Acute Hospitals NHS TrustDepartment of Obstetrics and GynaecologyManchesterUK
| | - Jade Baker
- Pennine Acute Hospitals NHS TrustDepartment of Obstetrics and GynaecologyManchesterUK
| | | | - Kevin Phillips
- Castle Hill HospitalObstetrics and GynaecologyCastle RoadCottinghamNorth HumbersideUKHU16 5JQ
| | - Andrew Watson
- Tameside & Glossop Acute Services NHS TrustDepartment of Obstetrics and GynaecologyFountain StreetAshton‐Under‐LyneLancashireUKOL6 9RW
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Upchurch E, Ragusa M, Cirocchi R. Stent placement versus surgical palliation for adults with malignant gastric outlet obstruction. Cochrane Database Syst Rev 2018; 5:CD012506. [PMID: 29845610 PMCID: PMC6494580 DOI: 10.1002/14651858.cd012506.pub2] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Malignant gastric outlet obstruction is the clinical and pathological consequence of cancerous disease causing a mechanical obstruction to gastric emptying. It usually occurs when malignancy is at an advanced stage; therefore, people have a limited life expectancy. It is of paramount importance to restore oral intake to improve quality of life for the person in a manner that has a minimal risk of complications and a short recovery period. OBJECTIVES To assess the benefits and harms of endoscopic stent placement versus surgical palliation for people with symptomatic malignant gastric outlet obstruction. SEARCH METHODS In May 2018 we searched the Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Ovid Embase and Ovid CINAHL. We screened reference lists from included studies and review articles. SELECTION CRITERIA We included randomised controlled trials comparing stent placement with surgical palliation for people with gastric outlet obstruction secondary to malignant disease. DATA COLLECTION AND ANALYSIS Two review authors independently extracted study data. We calculated the risk ratio (RR) with 95% confidence intervals (CI) for binary outcomes, mean difference (MD) or standardised mean difference (SMD) with 95% CI for continuous outcomes and the hazard ratio (HR) for time-to-event outcomes. We performed meta-analyses where meaningful. We assessed the quality of evidence using GRADE criteria. MAIN RESULTS We identified three randomised controlled trials with 84 participants. Forty-one participants underwent surgical palliation and 43 participants underwent duodenal stent placement. There may have been little or no difference in the technical success of the procedure (RR 0.98, 95% CI 0.88 to 1.09; low-quality evidence), or whether the time to resumption of oral intake was quicker for participants who had undergone duodenal stent placement (MD -3.07 days, 95% CI -4.76 to -1.39; low-quality evidence).Due to very low-quality evidence, we were uncertain whether surgical palliation improved all-cause mortality and median survival postintervention.The time to recurrence of obstructive symptoms may have increased slightly following duodenal stenting (RR 5.08, 95% CI 0.96 to 26.74; moderate-quality evidence).Due to very low-quality evidence, we were uncertain whether surgical palliation improved serious and minor adverse events. The heterogeneity for adverse events was moderately high (serious adverse events: Chi² = 1.71; minor adverse events: Chi² = 3.08), reflecting the differences in definitions used and therefore, may have impacted the outcomes. The need for reintervention may have increased following duodenal stenting (RR 4.71, 95% CI 1.36 to 16.30; very low-quality evidence).The length of hospital stay may have been shorter (by approximately 4 to 10 days) following stenting (MD -6.70 days, 95% CI -9.41 to -3.98; moderate-quality evidence). AUTHORS' CONCLUSIONS The use of duodenal stent placement in malignant gastric outlet obstruction has the benefits of a quicker resumption of oral intake and a reduced inpatient hospital stay; however, this is balanced by an increase in the recurrence of symptoms and the need for further intervention.It is impossible to draw further conclusions on these and the other measured outcomes, primarily due to the low number of eligible studies and small number of participants which resulted in low-quality evidence. It was not possible to analyse the impact on quality of life each intervention had for these participants.
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Affiliation(s)
- Emma Upchurch
- Gloucestershire Hospitals NHS Foundation TrustDepartment of Colorectal and Upper Gastrointestinal SurgerySandford RoadCheltenhamGloucestershireUKGL53 7AN
| | | | - Roberto Cirocchi
- University of PerugiaDepartment of General SurgeryTerniItaly05100
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Upchurch E, Cirocchi R, Ragusa M. Stent placement versus surgical palliation for malignant gastric outlet obstruction. Hippokratia 2017. [DOI: 10.1002/14651858.cd012506] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Emma Upchurch
- Gloucestershire Hospitals NHS Foundation Trust; Department of Colorectal and Upper Gastrointestinal Surgery; Sandford Road Cheltenham Gloucestershire UK GL53 7AN
| | - Roberto Cirocchi
- University of Perugia; Department of General Surgery; Terni Italy 05100
| | - Mark Ragusa
- Perugia University Medical School; Terni Italy
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Development of a novel simulation model for assessment of laparoscopic camera navigation. Surg Endosc 2016; 31:3033-3039. [PMID: 27826776 DOI: 10.1007/s00464-016-5323-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 10/31/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Laparoscopic camera navigation is vital to laparoscopic surgery, yet often falls to the most junior member of the surgical team who has limited laparoscopic operating experience. Previously published reports on simulation models fail to address qualitative scoring of movement, method of communication and correct physician location with respect to patient position. The purpose of this study was to develop and evaluate a novel laparoscopic camera navigation simulation model that addresses these deficiencies. METHODS A novel, low-cost laparoscopic camera navigational maze was constructed from pliable foam for use in a standard laparoscopic surgery box trainer. Participants (n = 37) completed a camera navigation exercise by following a pre-recorded set of verbal instructions using correct anatomic terminology that is used in the operating room, to simulate an actual operating room experience of receiving verbal cues from senior surgeons. The sample group consisted of participants at various levels of Obstetrics and Gynecology training, representing novice to expert laparoscopists. Each trial was recorded with a multi-channel video camera. Performances were scored by a blinded evaluator for excess gross and fine camera movements as well as overt errors, including camera collisions and failure to follow directions. RESULTS Our model demonstrated evidence of validity by discriminating performance by level of laparoscopic experience with a statistically significant decrease in number of movements and errors in experts compared to novices. A trend emerged toward improvement with each additional year of training, with reduced variability among performances in more experienced participants. CONCLUSIONS This novel, low-cost box-trainer simulation model for laparoscopic camera navigation offers a mechanism for assessment of laparoscopic camera operation skills. Moreover, this model closely replicates operating room logistics and communication. Given the necessity for improved laparoscopic camera operation education, our model represents a unique, complementary tool to other laparoscopic simulation curricula.
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Zhang H, Liu X, Jiang H, Liu Z, Zhang XY, Xie HZ. Parecoxib increases muscle pain threshold and relieves shoulder pain after gynecologic laparoscopy: a randomized controlled trial. J Pain Res 2016; 9:653-660. [PMID: 27695359 PMCID: PMC5028176 DOI: 10.2147/jpr.s115889] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Objectives Postlaparoscopic shoulder pain (PLSP) remains a common problem after laparoscopies. The aim of this study was to investigate the correlation between pressure pain threshold (PPT) of different muscles and PLSP after gynecologic laparoscopy, and to explore the effect of parecoxib, a cyclooxygenase-2 inhibitor, on the changes of PPT. Materials and methods The patients were randomly allocated into two groups; group P and group C. In group P, parecoxib 40 mg was intravenously infused at 30 minutes before surgery and 8 and 20 hours after surgery. In group C, normal saline was infused at the corresponding time point. PPT assessment was performed 1 day before surgery and at postoperative 24 hours by using a pressure algometer at bilateral shoulder muscles (levator scapulae and supraspinatus) and forearm (flexor carpi ulnaris). Meanwhile, bilateral shoulder pain was evaluated through visual analog scale score at 24 hours after surgery. Results Preoperative PPT level of the shoulder, but not of the forearm, was significantly and negatively correlated with the intensity of ipsilateral PLSP. In group C, PPT levels of shoulder muscles, but not of forearm muscles, decreased after laparoscopy at postoperative 24 hours. The use of parecoxib significantly improved the decline of PPT levels of bilateral shoulder muscles (all P<0.01). Meanwhile, parecoxib reduced the incidence of PLSP (group P: 45% vs group C: 83.3%; odds ratio: 0.164; 95% confidence interval: 0.07–0.382; P<0.001) and the intensity of bilateral shoulder pain (both P<0.01). Conclusion Preoperative PPT levels of shoulder muscles are closely associated with the severity of shoulder pain after gynecologic laparoscopy. PPT levels of shoulder muscles, but not of forearm muscles, significantly decreased after surgery. Parecoxib improved the decrease of PPT and relieved PLSP.
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Affiliation(s)
- Hufei Zhang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou
| | - Xinhe Liu
- Department of Anesthesiology, Shenzhen Hospital, University of Hong Kong, Shenzhen
| | | | - Zimeng Liu
- Surgical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Xu-Yu Zhang
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou
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Mavrova R, Radosa JC, Wagenpfeil G, Hamza A, Solomayer EF, Juhasz-Böss I. Learning curves for laparoscopic hysterectomy after implementation of minimally invasive surgery. Int J Gynaecol Obstet 2016; 134:225-30. [DOI: 10.1016/j.ijgo.2016.01.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 01/20/2016] [Accepted: 04/28/2016] [Indexed: 10/21/2022]
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Riviere D, Gurusamy KS, Kooby DA, Vollmer CM, Besselink MGH, Davidson BR, van Laarhoven CJHM. Laparoscopic versus open distal pancreatectomy for pancreatic cancer. Cochrane Database Syst Rev 2016; 4:CD011391. [PMID: 27043078 PMCID: PMC7083263 DOI: 10.1002/14651858.cd011391.pub2] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Surgical resection is currently the only treatment with the potential for long-term survival and cure of pancreatic cancer. Surgical resection is provided as distal pancreatectomy for cancers of the body and tail of the pancreas. It can be performed by laparoscopic or open surgery. In operations on other organs, laparoscopic surgery has been shown to reduce complications and length of hospital stay as compared with open surgery. However, concerns remain about the safety of laparoscopic distal pancreatectomy compared with open distal pancreatectomy in terms of postoperative complications and oncological clearance. OBJECTIVES To assess the benefits and harms of laparoscopic distal pancreatectomy versus open distal pancreatectomy for people undergoing distal pancreatectomy for pancreatic ductal adenocarcinoma of the body or tail of the pancreas, or both. SEARCH METHODS We used search strategies to search the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Science Citation Index Expanded and trials registers until June 2015 to identify randomised controlled trials (RCTs) and non-randomised studies. We also searched the reference lists of included trials to identify additional studies. SELECTION CRITERIA We considered for inclusion in the review RCTs and non-randomised studies comparing laparoscopic versus open distal pancreatectomy in patients with resectable pancreatic cancer, irrespective of language, blinding or publication status.. DATA COLLECTION AND ANALYSIS Two review authors independently identified trials and independently extracted data. We calculated odds ratios (ORs), mean differences (MDs) or hazard ratios (HRs) along with 95% confidence intervals (CIs) using both fixed-effect and random-effects models with RevMan 5 on the basis of intention-to-treat analysis when possible. MAIN RESULTS We found no RCTs on this topic. We included in this review 12 non-randomised studies that compared laparoscopic versus open distal pancreatectomy (1576 participants: 394 underwent laparoscopic distal pancreatectomy and 1182 underwent open distal pancreatectomy); 11 studies (1506 participants: 353 undergoing laparoscopic distal pancreatectomy and 1153 undergoing open distal pancreatectomy) provided information for one or more outcomes. All of these studies were retrospective cohort-like studies or case-control studies. Most were at unclear or high risk of bias, and the overall quality of evidence was very low for all reported outcomes.Differences in short-term mortality (laparoscopic group: 1/329 (adjusted proportion based on meta-analysis estimate: 0.5%) vs open group: 11/1122 (1%); OR 0.48, 95% CI 0.11 to 2.17; 1451 participants; nine studies; I(2) = 0%), long-term mortality (HR 0.96, 95% CI 0.82 to 1.12; 277 participants; three studies; I(2) = 0%), proportion of people with serious adverse events (laparoscopic group: 7/89 (adjusted proportion: 8.8%) vs open group: 6/117 (5.1%); OR 1.79, 95% CI 0.53 to 6.06; 206 participants; three studies; I(2) = 0%), proportion of people with a clinically significant pancreatic fistula (laparoscopic group: 9/109 (adjusted proportion: 7.7%) vs open group: 9/137 (6.6%); OR 1.19, 95% CI 0.47 to 3.02; 246 participants; four studies; I(2) = 61%) were imprecise. Differences in recurrence at maximal follow-up (laparoscopic group: 37/81 (adjusted proportion based on meta-analysis estimate: 36.3%) vs open group: 59/103 (49.5%); OR 0.58, 95% CI 0.32 to 1.05; 184 participants; two studies; I(2) = 13%), adverse events of any severity (laparoscopic group: 33/109 (adjusted proportion: 31.7%) vs open group: 45/137 (32.8%); OR 0.95, 95% CI 0.54 to 1.66; 246 participants; four studies; I(2) = 18%) and proportion of participants with positive resection margins (laparoscopic group: 49/333 (adjusted proportion based on meta-analysis estimate: 14.3%) vs open group: 208/1133 (18.4%); OR 0.74, 95% CI 0.49 to 1.10; 1466 participants; 10 studies; I(2) = 6%) were also imprecise. Mean length of hospital stay was shorter by 2.43 days in the laparoscopic group than in the open group (MD -2.43 days, 95% CI -3.13 to -1.73; 1068 participants; five studies; I(2) = 0%). None of the included studies reported quality of life at any point in time, recurrence within six months, time to return to normal activity and time to return to work or blood transfusion requirements. AUTHORS' CONCLUSIONS Currently, no randomised controlled trials have compared laparoscopic distal pancreatectomy versus open distal pancreatectomy for patients with pancreatic cancers. In observational studies, laparoscopic distal pancreatectomy has been associated with shorter hospital stay as compared with open distal pancreatectomy. Currently, no information is available to determine a causal association in the differences between laparoscopic versus open distal pancreatectomy. Observed differences may be a result of confounding due to laparoscopic operation on less extensive cancer and open surgery on more extensive cancer. In addition, differences in length of hospital stay are relevant only if laparoscopic and open surgery procedures are equivalent oncologically. This information is not available currently. Thus, randomised controlled trials are needed to compare laparoscopic distal pancreatectomy versus open distal pancreatectomy with at least two to three years of follow-up. Such studies should include patient-oriented outcomes such as short-term mortality and long-term mortality (at least two to three years); health-related quality of life; complications and the sequelae of complications; resection margins; measures of earlier postoperative recovery such as length of hospital stay, time to return to normal activity and time to return to work (in those who are employed); and recurrence of cancer.
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Affiliation(s)
- Deniece Riviere
- Radboud University Nijmegen Medical CenterDepartment of SurgeryNijmegenNetherlands
| | - Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
| | - David A Kooby
- Emory University School of MedicineDepartment of SurgeryAtlantaGAUSA
| | - Charles M Vollmer
- University of PennsylvaniaDepartment of Gastrointestinal SurgeryPerelman School of MedicinePhiladelphiaPAUSA
| | - Marc GH Besselink
- AMC AmsterdamDepartment of Surgery, G4‐196PO Box 22660AmsterdamAMCNetherlands1100 DD
| | - Brian R Davidson
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
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Gurusamy KS, Pallari E, Midya S, Mughal M. Laparoscopic versus open transhiatal oesophagectomy for oesophageal cancer. Cochrane Database Syst Rev 2016; 3:CD011390. [PMID: 27030301 PMCID: PMC7086382 DOI: 10.1002/14651858.cd011390.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Surgery is the preferred treatment for resectable oesophageal cancers, and can be performed in different ways. Transhiatal oesophagectomy (oesophagectomy without thoracotomy, with a cervical anastomosis) is one way to resect oesophageal cancers. It can be performed laparoscopically or by open method. With other organs, laparoscopic surgery has been shown to reduce complications and length of hospital stay compared to open surgery. However, concerns remain about the safety of laparoscopic transhiatal oesophagectomy in terms of post-operative complications and oncological clearance compared with open transhiatal oesophagectomy. OBJECTIVES To assess the benefits and harms of laparoscopic versus open oesophagectomy for people with oesophageal cancer undergoing transhiatal oesophagectomy. SEARCH METHODS We electronically searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and trials registers until August 2015. We also searched the references of included trials to identify further trials. SELECTION CRITERIA We considered randomised controlled trials and non-randomised studies comparing laparoscopic with open transhiatal oesophagectomy in patients with resectable oesophageal cancer, regardless of language, blinding, or publication status for the review. DATA COLLECTION AND ANALYSIS Three review authors independently identified trials, assessed risk of bias and extracted data. We calculated the risk ratio (RR) or hazard ratio (HR) with 95% confidence intervals (CI), using both fixed-effect and random-effects models, with RevMan 5, based on intention-to-treat analyses. MAIN RESULTS We found no randomised controlled trials on this topic. We included six non-randomised studies (five retrospective) that compared laparoscopic versus open transhiatal oesophagectomy (334 patients: laparoscopic = 154 patients; open = 180 patients); five studies (326 patients: laparoscopic = 151 patients; open = 175 patients) provided information for one or more outcomes. Most studies included a mixture of adenocarcinoma and squamous cell carcinoma and different stages of oesophageal cancer, without metastases. All the studies were at unclear or high risk of bias; the overall quality of evidence was very low for all the outcomes.The differences between laparoscopic and open transhiatal oesophagectomy were imprecise for short-term mortality (laparoscopic = 0/151 (adjusted proportion based on meta-analysis estimate: 0.5%) versus open = 2/175 (1.1%); RR 0.44; 95% CI 0.05 to 4.09; participants = 326; studies = 5; I² = 0%); long-term mortality (HR 0.97; 95% CI 0.81 to 1.16; participants = 193; studies = 2; I² = 0%); anastomotic stenosis (laparoscopic = 4/36 (11.1%) versus open = 3/37 (8.1%); RR 1.37; 95% CI 0.33 to 5.70; participants = 73; studies = 1); short-term recurrence (laparoscopic = 1/16 (6.3%) versus open = 0/4 (0%); RR 0.88; 95% CI 0.04 to 18.47; participants = 20; studies = 1); long-term recurrence (HR 1.00; 95% CI 0.84 to 1.18; participants = 173; studies = 2); proportion of people who required blood transfusion (laparoscopic = 0/36 (0%) versus open = 6/37 (16.2%); RR 0.08; 95% CI 0.00 to 1.35; participants = 73; studies = 1); proportion of people with positive resection margins (laparoscopic = 15/102 (15.8%) versus open = 27/111 (24.3%); RR 0.65; 95% CI 0.37 to 1.12; participants = 213; studies = 3; I² = 0%); and the number of lymph nodes harvested during surgery (median difference between the groups varied from 12 less to 3 more lymph nodes in the laparoscopic compared to the open group; participants = 326; studies = 5).The proportion of patients with serious adverse events was lower in the laparoscopic group (10/99, (10.3%) compared to the open group = 24/114 (21.1%); RR 0.49; 95% CI 0.24 to 0.99; participants = 213; studies = 3; I² = 0%); as it was for adverse events in the laparoscopic group = 37/99 (39.9%) versus the open group = 71/114 (62.3%); RR 0.64; 95% CI 0.48 to 0.86; participants = 213; studies = 3; I² = 0%); and the median lengths of hospital stay were significantly less in the laparoscopic group than the open group (three days less in all three studies that reported this outcome; number of participants = 266). There was lack of clarity as to whether the median difference in the quantity of blood transfused was statistically significant favouring laparoscopic oesophagectomy in the only study that reported this information. None of the studies reported post-operative dysphagia, health-related quality of life, time-to-return to normal activity (return to pre-operative mobility without caregiver support), or time-to-return to work. AUTHORS' CONCLUSIONS There are currently no randomised controlled trials comparing laparoscopic with open transhiatal oesophagectomy for patients with oesophageal cancers. In observational studies, laparoscopic transhiatal oesophagectomy is associated with fewer overall complications and shorter hospital stays than open transhiatal oesophagectomy. However, this association is unlikely to be causal. There is currently no information to determine a causal association in the differences between the two surgical approaches. Randomised controlled trials comparing laparoscopic transhiatal oesophagectomy with other methods of oesophagectomy are required to determine the optimal method of oesophagectomy.
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Affiliation(s)
- Kurinchi Selvan Gurusamy
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRoyal Free HospitalRowland Hill StreetLondonUKNW3 2PF
| | - Elena Pallari
- University College LondonDepartment of General Surgery4th Floor, Rockefeller Building21 University StreetLondonUKWC1E 6DE
- King's College London School of MedicineDivision of Cancer Studies, Cancer Epidemiology GroupGuy's Hospital, Great Maze PondResearch OncologyLondonUKSE1 6RT
| | - Sumit Midya
- Royal Berkshire HospitalDepartment of General SurgeryReadingUKRG1 5AN
- University College LondonDivision of Surgery and Interventional ScienceLondonUK
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Abstract
BACKGROUND Gastric cancer is the third most common cause of cancer-related mortality in the world. Currently there are two surgical options for potentially curable patients (i.e. people with non-metastatic gastric cancer), laparoscopic and open gastrectomy. However, it is not clear whether one of these options is superior. OBJECTIVES To assess the benefits and harms of laparoscopic gastrectomy or laparoscopy-assisted gastrectomy versus open gastrectomy for people with gastric cancer. In particular, we planned to investigate the effects by patient groups, such as cancer stage, anaesthetic risk, and body mass index (BMI), and by intervention methods, such as method of anastomosis, type of gastrectomy and laparoscopic or laparoscopically-assisted gastrectomy. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Science Citation Index, ClinicalTrials.gov and the WHO ICTRP (World Health Organization International Clinical Trials Registry Platform) until September 2015. We also screened reference lists from included trials. SELECTION CRITERIA Two review authors independently selected references for further assessment by going through all titles and abstracts. Further selection was based on review of full text articles for selected references. DATA COLLECTION AND ANALYSIS Two review authors independently extracted study data. We calculated the risk ratio (RR) with 95% confidence interval (CI) for binary outcomes, the mean difference (MD) or the standardised mean difference (SMD) with 95% CI for continuous outcomes and the hazard ratio (HR) for time-to-event outcomes. We performed meta-analyses where it was meaningful. MAIN RESULTS In total, 2794 participants were randomised in 13 trials included in this review. All the trials were at unclear or high risk of bias. One trial (which included 53 participants) did not contribute any data to this review. A total of 213 participants were excluded in the remaining trials after randomisation, leaving a total of 2528 randomised participants for analysis, with 1288 undergoing laparoscopic gastrectomy and 1240 undergoing open gastrectomy. All the participants were suitable for major surgery.There was no difference in the proportion of participants who died within thirty days of treatment between laparoscopic gastrectomy (7/1188: adjusted proportion = 0.6% (based on meta-analysis)) and open gastrectomy (4/1447: 0.3%) (RR 1.60, 95% CI 0.50 to 5.10; risk difference 0.00, 95% CI -0.01 to 0.01; participants = 2335; studies = 11; I(2) = 0%; low quality evidence). There were no events in either group for short-term recurrence (participants = 103; studies = 3), proportion requiring blood transfusion (participants = 66; studies = 2), and proportion with positive margins at histopathology (participants = 28; studies = 1). None of the trials reported health-related quality of life, time to return to normal activity or time to return to work. The differences in long-term mortality (HR 0.94, 95% CI 0.70 to 1.25; participants = 195; studies = 3; I(2) = 0%; very low quality evidence), serious adverse events within three months (laparoscopic gastrectomy (7/216: adjusted proportion = 3.6%) versus open gastrectomy (13/216: 6%) (RR 0.60, 95% CI 0.27 to 1.34; participants = 432; studies = 8; I(2) = 0%; very low quality evidence), long-term recurrence (HR 0.95, 95% CI 0.70 to 1.30; participants = 162; studies = 4; very low quality evidence), adverse events within three months (laparoscopic gastrectomy (204/268: adjusted proportion = 16.1%) versus open gastrectomy (253/1222: 20.7%) (RR 0.78, 95% CI 0.60 to 1.01; participants = 2490; studies = 11; I(2) = 38%; very low quality evidence), quantity of perioperative blood transfused (SMD 0.05, 95% CI -0.27 to 0.38; participants = 143; studies = 2; I(2) = 0%; very low quality evidence), length of hospital stay (MD -1.82 days, 95% CI -3.72 to 0.07; participants = 319; studies = 6; I(2) = 83%; very low quality evidence), and number of lymph nodes harvested (MD -0.63, 95% CI -1.51 to 0.25; participants = 472; studies = 9; I(2) = 40%; very low quality evidence) were imprecise. There was no alteration in the interpretation of the results in any of the subgroups. AUTHORS' CONCLUSIONS Based on low quality evidence, there is no difference in short-term mortality between laparoscopic and open gastrectomy. Based on very low quality evidence, there is no evidence for any differences in short-term or long-term outcomes between laparoscopic and open gastrectomy. However, the data are sparse, and the confidence intervals were wide, suggesting that significant benefits or harms of laparoscopic gastrectomy cannot be ruled out. Several trials are currently being conducted and interim results of these trials have been included in this review. These trials need to perform intention-to-treat analysis to ensure that the results are reliable and report the results according to the CONSORT Statement.
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Affiliation(s)
- Lawrence MJ Best
- Royal Free Campus, UCL Medical SchoolDepartment of SurgeryRowland Hill StreetLondonUKNW32PF
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Kwon JS. Ovarian cancer risk reduction through opportunistic salpingectomy. J Gynecol Oncol 2016; 26:83-6. [PMID: 25872888 PMCID: PMC4397236 DOI: 10.3802/jgo.2015.26.2.83] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 04/01/2015] [Indexed: 12/18/2022] Open
Affiliation(s)
- Janice S Kwon
- Division of Gynecologic Oncology, University of British Columbia and British Columbia Cancer Agency, Vancouver, BC, Canada.
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Abstract
As more complex cases and larger uterine specimens are able to be managed with minimally invasive surgery, the limitations of tissue retrieval with these methods are of increasing concern. Risks of morcellator-related injury, tissue dissemination, or fragmentation must be weighed against increased morbidity of abdominal approach to hysterectomy. In an effort to mitigate the risks of tissue morcellation, containment system use must be considered when fragmenting a specimen, either with power morcellation or a manual technique via the vagina or minilaparotomy.
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Abstract
BACKGROUND Laparoscopy is a common procedure in many surgical specialities. Complications arising from laparoscopy are often related to initial entry into the abdomen. Life-threatening complications include injury to viscera e.g. the bowel or bladder, or to vasculature e.g. major abdominal and anterior abdominal wall vessels. Minor complications can also occur, such as postoperative wound infection, subcutaneous emphysema, and extraperitoneal insufflation. There is no clear consensus as to the optimal method of laparoscopic entry into the peritoneal cavity. OBJECTIVES To evaluate the benefits and risks of different laparoscopic entry techniques in gynaecological and non-gynaecological surgery. SEARCH METHODS This updated review has drawn on the search strategy developed by the Cochrane Menstrual Disorders and Subfertility Group. In addition, MEDLINE, EMBASE, CENTRAL and PsycINFO were searched through to September 2014. SELECTION CRITERIA We included randomised controlled trials (RCTs) in which one laparoscopic entry technique was compared with another. DATA COLLECTION AND ANALYSIS Two authors independently selected studies, assessed risk of bias, and extracted data. We expressed findings as Peto odds ratios (Peto ORs) with 95% confidence intervals (CIs). We assessed statistical heterogeneity using the I² statistic. We assessed the overall quality of evidence for the main comparisons using GRADE methods. MAIN RESULTS The review included 46 RCTs including three multi-arm trials (7389 participants) and evaluated 13 laparoscopic entry techniques. Overall there was no evidence of advantage using any single technique for preventing major vascular or visceral complications. The evidence was generally of very low quality; the main limitations were imprecision and poor reporting of study methods. Open-entry versus closed-entry There was no evidence of a difference between the groups for vascular (Peto OR 0.14, 95% CI 0.00 to 6.82, three RCTs, n = 795, I(2) = n/a; very low quality evidence) or visceral injury (Peto OR 0.61, 95% CI 0.06 to 6.08, three RCTs, n = 795, I(2) = 0%; very low quality evidence). There was a lower risk of failed entry in the open-entry group (Peto OR 0.16, 95% CI 0.04 to 0.63, n = 665, two RCTs, I(2) = 0%; very low quality evidence). This suggests that for every 1000 patients operated on, 31 patients in the closed-entry group will have failed entry compared to between 1 to 20 patients in the open-entry group. No events were reported in any of the studies for mortality, gas embolism or solid organ injury. Direct trocar versus Veress needle entry There was a lower risk of vascular injury in the direct trocar group (Peto OR 0.13, 95% CI 0.03 to 0.66, five RCTs, n = 1522, I(2) = 0%; low quality evidence) and failed entry (Peto OR 0.21, 95% CI 0.14 to 0.30, seven RCTs, n = 3104; I ²= 0%; moderate quality evidence). This suggests that for every 1000 patients operated on, 8 patients in the Veress needle group will experience vascular injury compared to between 0 to 5 patients in the direct trocar group; and that 64 patients in the Veress needle group will experience failed entry compared to between 10 to 20 patients in the direct trocar group. The vascular injury significance is sensitive to choice of statistical analysis and may be unreliable. There was no evidence of a difference between the groups for visceral (Peto OR 1.02, 95% CI 0.06 to 16.24, four RCTs, n = 1438, I(2) = 49%; very low quality evidence) or solid organ injury (Peto OR 0.16, 95% Cl 0.01 to 2.53, two RCTs, n = 998, I(2) = n/a; very low quality evidence). No events were recorded for mortality or gas embolism. Direct vision entry versus Veress needle entry There was no evidence of a difference between the groups in the rates of visceral injury (Peto OR 0.15, 95% CI 0.01 to 2.34, one RCT, n = 194; very low quality evidence). Other primary outcomes were not reported. Direct vision entry versus open-entry There was no evidence of a difference between the groups in the rates of visceral injury (Peto OR 0.13, 95% CI 0.00 to 6.50, two RCTs, n = 392; low quality evidence), solid organ injury (Peto OR 6.16, 95% CI 0.12 to 316.67, one RCT, n = 60, I(2) = n/a; very low quality evidence), or failed entry (Peto OR 0.40, 95% CI 0.04 to 4.09, one RCT, n = 60; low quality evidence). Vascular injury was reported, however no events occurred. Our other primary outcomes were not reported. Radially expanding (STEP) trocars versus non-expanding trocars There was no evidence of a difference between the groups for vascular injury (Peto OR 0.24, 95% Cl 0.05 to 1.21, two RCTs, n = 331, I(2) = 0%; low quality evidence), visceral injury (Peto OR 0.13, 95% CI 0.00 to 6.37, two RCTs, n = 331, I(2) = n/a; low quality evidence), or solid organ injury (Peto OR 1.05, 95% CI 0.07 to 16.91, one RCT, n = 244; very low quality evidence). Other primary outcomes were not reported. Comparisons of other laparoscopic entry techniquesThere was a higher risk of failed entry in the group in which the abdominal wall was lifted before Veress needle insertion than in the not-lifted group (Peto OR 4.44, 95% CI 2.16 to 9.13, one RCT, n = 150; very low quality evidence). There was no evidence of a difference between the groups in rates of visceral injury or extraperitoneal insufflation. The studies had small numbers and excluded many patients with previous abdominal surgery, and women with a raised body mass index. These patients may have unusually high complication rates. AUTHORS' CONCLUSIONS Overall, there is insufficient evidence to recommend one laparoscopic entry technique over another.An open-entry technique is associated with a reduction in failed entry when compared to a closed-entry technique, with no evidence of a difference in the incidence of visceral or vascular injury.An advantage of direct trocar entry over Veress needle entry was noted for failed entry and vascular injury. The evidence was generally of very low quality with small numbers of participants in most studies; our findings should be interpreted with caution.
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Affiliation(s)
- Gaity Ahmad
- Department of Obstetrics and Gynaecology, Pennine Acute Hospitals NHS Trust, Manchester, UK
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Aarts JWM, Nieboer TE, Johnson N, Tavender E, Garry R, Mol BWJ, Kluivers KB. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2015; 2015:CD003677. [PMID: 26264829 PMCID: PMC6984437 DOI: 10.1002/14651858.cd003677.pub5] [Citation(s) in RCA: 261] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The four approaches to hysterectomy for benign disease are abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH) and robotic-assisted hysterectomy (RH). OBJECTIVES To assess the effectiveness and safety of different surgical approaches to hysterectomy for women with benign gynaecological conditions. SEARCH METHODS We searched the following databases (from inception to 14 August 2014) using the Ovid platform: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. We also searched relevant citation lists. We used both indexed and free-text terms. SELECTION CRITERIA We included randomised controlled trials (RCTs) in which clinical outcomes were compared between one surgical approach to hysterectomy and another. DATA COLLECTION AND ANALYSIS At least two review authors independently selected trials, assessed risk of bias and performed data extraction. Our primary outcomes were return to normal activities, satisfaction, quality of life, intraoperative visceral injury and major long-term complications (i.e. fistula, pelvi-abdominal pain, urinary dysfunction, bowel dysfunction, pelvic floor condition and sexual dysfunction). MAIN RESULTS We included 47 studies with 5102 women. The evidence for most comparisons was of low or moderate quality. The main limitations were poor reporting and imprecision. Vaginal hysterectomy (VH) versus abdominal hysterectomy (AH) (nine RCTs, 762 women)Return to normal activities was shorter in the VH group (mean difference (MD) -9.5 days, 95% confidence interval (CI) -12.6 to -6.4, three RCTs, 176 women, I(2) = 75%, moderate quality evidence). There was no evidence of a difference between the groups for the other primary outcomes. Laparoscopic hysterectomy (LH) versus AH (25 RCTs, 2983 women)Return to normal activities was shorter in the LH group (MD -13.6 days, 95% CI -15.4 to -11.8; six RCTs, 520 women, I(2) = 71%, low quality evidence), but there were more urinary tract injuries in the LH group (odds ratio (OR) 2.4, 95% CI 1.2 to 4.8, 13 RCTs, 2140 women, I(2) = 0%, low quality evidence). There was no evidence of a difference between the groups for the other primary outcomes. LH versus VH (16 RCTs, 1440 women)There was no evidence of a difference between the groups for any primary outcomes. Robotic-assisted hysterectomy (RH) versus LH (two RCTs, 152 women)There was no evidence of a difference between the groups for any primary outcomes. Neither of the studies reported satisfaction rates or quality of life.Overall, the number of adverse events was low in the included studies. AUTHORS' CONCLUSIONS Among women undergoing hysterectomy for benign disease, VH appears to be superior to LH and AH, as it is associated with faster return to normal activities. When technically feasible, VH should be performed in preference to AH because of more rapid recovery and fewer febrile episodes postoperatively. Where VH is not possible, LH has some advantages over AH (including more rapid recovery and fewer febrile episodes and wound or abdominal wall infections), but these are offset by a longer operating time. No advantages of LH over VH could be found; LH had a longer operation time, and total laparoscopic hysterectomy (TLH) had more urinary tract injuries. Of the three subcategories of LH, there are more RCT data for laparoscopic-assisted vaginal hysterectomy and LH than for TLH. Single-port laparoscopic hysterectomy and RH should either be abandoned or further evaluated since there is a lack of evidence of any benefit over conventional LH. Overall, the evidence in this review has to be interpreted with caution as adverse event rates were low, resulting in low power for these comparisons. The surgical approach to hysterectomy should be discussed and decided in the light of the relative benefits and hazards. These benefits and hazards seem to be dependent on surgical expertise and this may influence the decision. In conclusion, when VH is not feasible, LH may avoid the need for AH, but LH is associated with more urinary tract injuries. There is no evidence that RH is of benefit in this population. Preferably, the surgical approach to hysterectomy should be decided by the woman in discussion with her surgeon.
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Affiliation(s)
- Johanna WM Aarts
- Radboud University Nijmegen Medical CenterDepartment of Obstetrics and GynaecologyGeert Grooteplein 10NijmegenNetherlands6500HB
| | - Theodoor E Nieboer
- Radboud University Nijmegen Medical CenterDepartment of Obstetrics and GynaecologyGeert Grooteplein 10NijmegenNetherlands6500HB
| | - Neil Johnson
- University of AdelaideRobinson Research InstituteNorwich Centre Ground Floor, 55 King William RoadNorth AdelaideAdelaideSouth AustraliaAustralia5006
| | - Emma Tavender
- Monash UniversityAustralian Satellite of the Cochrane EPOC Group, Department of SurgeryLevel 6, 99 Commercial RoadMelbourneVictoriaAustraliaVIC 3004
| | - Ray Garry
- University of Teeside and South Cleveland Hospital, MiddlesbroughGynaecological Surgery94 WestgateGuisboroughYorkshireUKTS14 6AP
| | - Ben Willem J Mol
- The University of AdelaideThe Robinson Institute, School of Paediatrics and Reproductive HealthLevel 3, Medical School South BuildingFrome RoadAdelaideSouth AustraliaAustraliaSA 5005
| | - Kirsten B Kluivers
- Radboud University Nijmegen Medical CenterDepartment of Obstetrics and GynaecologyGeert Grooteplein 10NijmegenNetherlands6500HB
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Ramos A, Fader AN. Minimally Invasive Surgery in Gynecology: Underutilized? CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2015. [DOI: 10.1007/s13669-015-0126-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bortoletto P, Einerson BD, Miller ES, Milad MP. Cost-Effectiveness Analysis of Morcellation Hysterectomy for Myomas. J Minim Invasive Gynecol 2015; 22:820-6. [DOI: 10.1016/j.jmig.2015.03.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Revised: 03/18/2015] [Accepted: 03/23/2015] [Indexed: 10/23/2022]
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Kokka F, Bryant A, Brockbank E, Powell M, Oram D. Hysterectomy with radiotherapy or chemotherapy or both for women with locally advanced cervical cancer. Cochrane Database Syst Rev 2015:CD010260. [PMID: 25847525 DOI: 10.1002/14651858.cd010260.pub2] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Cervical cancer is the second commonest cancer among women up to 65 years of age and is the most frequent cause of death from gynaecological cancers worldwide. Sources suggest that a very high proportion of new cervical cancer cases in developing countries are at an advanced stage (IB2 or more) and more than a half of these may be stage III or IV. Cervical cancer staging is based on findings from clinical examination (FIGO) staging). Standard care in Europe and US for stage IB2 to III is non-surgical treatment (chemoradiation). However in developing countries, where there is limited access to radiotherapy, locally advanced cervical cancer may be treated with a combination of chemotherapy and hysterectomy (surgery to remove the womb and the neck of the womb, with or without the surrounding tissues). It is not certain if this improves survival. Therefore, it is important to systematically assess the value of hysterectomy in addition to radiotherapy or chemotherapy, or both, as an alternative intervention in the treatment of locally advanced cervical cancer (stage IB2 to III). OBJECTIVES To determine whether hysterectomy, in addition to standard treatment with radiation or chemotherapy, or both, in women with locally advanced cervical cancer (stage IB2 to III) is safe and effective compared with standard treatment alone. SEARCH METHODS We searched the Cochrane Gynaecological Cancer Group Trials Register, CENTRAL, MEDLINE, EMBASE and LILACS up to February 2014. We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies. SELECTION CRITERIA We searched for randomised controlled trials (RCTs) that compared treatment protocols involving hysterectomy versus radiotherapy or chemotherapy, or both, in women with advanced stage (IB2 to III) cervical cancer presenting for the first time. DATA COLLECTION AND ANALYSIS We assessed study eligibility independently, extracted data and assessed risk of bias. Where possible, overall and progression or disease-free survival outcomes were synthesised in a meta-analysis using the random-effects model. Adverse events were incompletely reported so results of single trials were described in narrative form. MAIN RESULTS We included seven RCTs (1217 women) of varying methodological quality in the review; most trials were at moderate or high risk of bias.Three were multi-centre trials, two were single-centre trials, and in two trials it was unclear if they were single or multi-centre. These trials compared the following interventions for women with locally advanced cervical cancer (stages IB2 to III):hysterectomy (simple or radical) with radiotherapy (N = 194) versus radiotherapy alone (N = 180); hysterectomy (simple or radical) with chemoradiotherapy (N = 31) versus chemoradiotherapy alone (N = 30); hysterectomy (radical) with chemoradiotherapy (N = 111) versus internal radiotherapy with chemoradiotherapy (N = 100); hysterectomy (simple or radical) with upfront (neoadjuvant) chemotherapy (N = 298) versus radiotherapy alone (N = 273).One trial (N = 256) found no difference in the risk of death or disease progression between women who received attenuated radiotherapy followed by hysterectomy and those who received radiotherapy (external and internal) alone (hazard ratio (HR) 0.89, 95% confidence interval (CI) 0.61 to 1.29). This trial also reported no difference between the two groups in terms of adverse effects (18/129 grade 3 or 4 adverse effects in the hysterectomy and radiation group and 19 cases in 18/121 women in the radiotherapy alone group). There was no difference in 5-year tumour-free actuarial survival (representation of the probable years of survivorship of a defined population of participants) or severe complications (grade 3) in another trial (N = 118) which reported the same comparison (6/62 versus 6/56 in the radiation with surgery group versus the radiotherapy alone group, respectively). The quality of the evidence was low for all these outcomes.One trial (N = 61) reported no difference (P value > 0.10) in overall and recurrence-free survival at 3 years between chemoradiotherapy and hysterectomy versus chemoradiotherapy alone (low quality evidence). Adverse events and morbidity data were not reported.Similarly, another trial (N = 211) found no difference in the risk of death (HR 0.65, 95% CI 0.35 to 1.21, P value = 0.19, low quality evidence), disease progression (HR 0.70, 95% CI 0.31 to 1.34, P value = 0.24, low quality evidence) or severe late complications (P value = 0.53, low quality evidence) between women who received internal radiotherapy versus hysterectomy after both groups had received external-beam chemoradiotherapy.Meta analysis of three trials of neoadjuvant chemotherapy and hysterectomy versus radiotherapy alone, assessing 571 participants, found that women who received neoadjuvant chemotherapy plus hysterectomy had less risk of death than those who received radiotherapy alone (HR 0.71, 95% CI 0.55 to 0.93, I(2) = 0%, moderate quality evidence). However, a significant number of the participants that received neoadjuvant chemotherapy plus hysterectomy had radiotherapy as well. There was no difference in the proportion of women with disease progression or recurrence between the two groups (RR 0.75, 95% CI 0.53 to 1.05, I(2) = 20%, moderate quality evidence).Results of single trials reported no apparent (P value > 0.05) difference in long-term severe complications, grade 3 acute toxicity and severe late toxicity between the two groups (low quality evidence).Quality of life outcomes were not reported in any of the trials. AUTHORS' CONCLUSIONS From the available RCTs, we found insufficient evidence that hysterectomy with radiotherapy, with or without chemotherapy, improves the survival of women with locally advanced cervical cancer who are treated with radiotherapy or chemoradiotherapy alone. The overall quality of the evidence was variable across the different outcomes and was universally downgraded due to concerns about risk of bias. The quality of the evidence for neoadjuvant chemotherapy and radical hysterectomy versus radiotherapy alone for survival outcomes was moderate, with evidence from other comparisons of low quality. This was mainly based on poor reporting and sparseness of data where results were based on single trials. More trials that assess medical management with and without hysterectomy may test the robustness of the findings of this review as further research is likely to have an important impact on our confidence in the estimate of effect.
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Affiliation(s)
- Fani Kokka
- Women's Health, Birchington Ward, Queen Elizabeth The Queen Mother Hospital, St Peters Road, Kent, UK, CT9 4AN
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Babashov V, Palimaka S, Blackhouse G, O'Reilly D. Magnetic Resonance-Guided High-Intensity Focused Ultrasound (MRgHIFU) for Treatment of Symptomatic Uterine Fibroids: An Economic Analysis. ONTARIO HEALTH TECHNOLOGY ASSESSMENT SERIES 2015; 15:1-61. [PMID: 26357531 PMCID: PMC4558770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND Uterine fibroids, or leiomyomas, are the most common benign tumours in women of childbearing age. Some women experience symptoms (e.g., heavy bleeding) that require aggressive forms of treatment such as uterine artery embolization (UAE), myomectomy, magnetic resonance-guided high-intensity focused ultrasound (MRgHIFU), and even hysterectomy. It is important to note that hysterectomy is not appropriate for women who desire future childbearing. OBJECTIVES The objective of this analysis was to evaluate the cost-effectiveness and budgetary impact of implementing MRgHIFU as a treatment option for symptomatic uterine fibroids in premenopausal women for whom drugs have been ineffective. REVIEW METHODS We performed an original cost-effectiveness analysis to assess the long-term costs and effects of MRgHIFU compared with hysterectomy, myomectomy, and UAE as a strategy for treating symptomatic uterine fibroids in premenopausal women aged 40 to 51 years. We explored a number of scenarios, e.g., comparing MRgHIFU with uterine-preserving procedures only, considering MRgHIFU-eligible patients only, and eliminating UAE as a treatment option. In addition, we performed a one-year budget impact analysis, using data from Ontario administrative sources. Four scenarios were explored in the budgetary impact analysis: •MRgHIFU funded at 2 centres •MRgHIFU funded at 2 centres and replacing only uterine-preserving procedures •MRgHIFU funded at 6 centres •MRgHIFU funded at 6 centres and replacing only uterine-preserving procedures Analyses were conducted from the Ontario public payer perspective. RESULTS The base case determined that the uterine artery embolization (UAE) treatment strategy was the cost-effective option at commonly accepted willingness-to-pay values. Compared with hysterectomy, UAE was calculated as having an incremental cost-effectiveness ratio (ICER) of $46,480 per quality-adjusted life-year (QALY) gained. The MRgHIFU strategy was extendedly dominated by a combination of UAE and hysterectomy, and myomectomy was strictly dominated by MRgHIFU and UAE. In the scenario where only MRgHIFU-eligible patients were considered, MRgHIFU was the cost-effective option for a willingness-to-pay threshold of $50,000. In the scenario where only MRgHIFU-eligible patients were considered and where UAE was eliminated as a treatment option (due to its low historic utilization in Ontario), MRgHIFU was cost-effective with an incremental cost of $39,250 per additional QALY. The budgetary impact of funding MRgHIFU for treatment of symptomatic uterine fibroids was estimated at $1.38 million in savings when funded to replace all types of procedures at 2 centres, and $1.14 million when funded to replace only uterine-preserving procedures at 2 centres. The potential savings increase to $4.15 million when MRgHIFU is funded at 6 centres to treat all women eligible for the procedure. Potential savings at 6 centres decrease slightly, to $3.42 million, when MRgHIFU is funded to replace uterine-preserving procedures only. CONCLUSIONS Our findings suggest that MRgHIFU may be a cost-effective strategy at commonly accepted willingness-to-pay thresholds, after examining the uncertainty in model parameters and several likely scenarios. In terms of budget impact, the implementation of MRgHIFU could potentially result in one-year savings of $1.38 million and $4.15 million in the scenarios where MRgHIFU is implemented in 2 or 6 centres, respectively. From a patient perspective, it is important to consider that MRgHIFU is the least invasive of all fibroid treatment options for women who have not responded to pharmaceuticals; it is the only one that is completely noninvasive. Also important, from a societal point of view, is the potential benefit from faster recovery times. Despite these benefits, implementation of MRgHIFU beyond the 2 centres which currently offer the treatment faces logistical challenges (for example, competing demands for use of existing equipment), as well as financial challenges, with hospitals needing to fundraise to purchase new equipment.
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Analysis of hysterectomies for patients with uterine leiomyomas in China in 2010. Int J Gynaecol Obstet 2014; 129:71-4. [DOI: 10.1016/j.ijgo.2014.10.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 10/22/2014] [Accepted: 12/16/2014] [Indexed: 11/20/2022]
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Bouwsma EVA, Vonk Noordegraaf A, Szlávik Z, Brölmann HAM, Emanuel MH, Lips JP, van Mechelen W, Mozes A, Thurkow AL, Huirne JAF, Anema JR. Process evaluation of a multidisciplinary care program for patients undergoing gynaecological surgery. JOURNAL OF OCCUPATIONAL REHABILITATION 2014; 24:425-38. [PMID: 24057871 PMCID: PMC4118044 DOI: 10.1007/s10926-013-9475-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
PURPOSE This study describes the process evaluation of an innovative multidisciplinary care program for patients undergoing benign gynaecologic surgery. This care program aims at improving recovery and preventing delayed return to work and consists of two steps: (1) an interactive e-health intervention for all participants, and (2) integrated clinical and occupational care management for those participants whose sick leave exceeds 10 weeks. METHODS Eligible for this study were employed women aged between 18-65 years scheduled for a laparoscopic adnexal surgery and/or hysterectomy. Data were collected from patients, their supervisors and their gynaecologists, by means of electronic questionnaires during a 6 month follow-up period and an automatically generated, detailed weblog of the patient web portal ( www.ikherstel.nl ). Investigated process measures included: reach, dose delivered, dose received, and fidelity. In addition, attitudes towards the intervention were explored among all stakeholders. RESULTS 215 patients enrolled in the study and accounted to a reach of 60.2 % (215/357). All intervention group patients used their account at least once and total time spent on the patient web portal was almost 2 h for each patient (median 118 min, IQR 64-173 min). Most patients visited the website several times (median 11 times, IQR 6-16). Perceived effectiveness among patients was high (74 %). In addition, gynaecologists (76 %) and employers (61 %) were satisfied with the web portal as well. Implementation of the second step of the intervention was suboptimal. Motivating patients to consent to additional guidance and developing an accurate return-to-work-prognosis were two important obstacles. CONCLUSIONS The results of this study indicate good feasibility for implementation on a broad scale of the e-health intervention for patients undergoing benign gynaecological surgery. To enhance the implementation of the second step of the perioperative care program, adaptations in the integrated care protocol are needed.
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Affiliation(s)
- E V A Bouwsma
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands,
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Falcone F, Balbi G, Di Martino L, Grauso F, Salzillo ME, Messalli EM. Surgical management of early endometrial cancer: an update and proposal of a therapeutic algorithm. Med Sci Monit 2014; 20:1298-313. [PMID: 25063051 PMCID: PMC4136932 DOI: 10.12659/msm.890478] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
In the last few years technical improvements have produced a dramatic shift from traditional open surgery towards a minimally invasive approach for the management of early endometrial cancer. Advancement in minimally invasive surgical approaches has allowed extensive staging procedures to be performed with significantly reduced patient morbidity. Debate is ongoing regarding the choice of a minimally invasive approach that has the most effective benefit for the patients, the surgeon, and the healthcare system as a whole. Surgical treatment of women with presumed early endometrial cancer should take into account the features of endometrial disease and the general surgical risk of the patient. Women with endometrial cancer are often aged, obese, and with cardiovascular and metabolic comorbidities that increase the risk of peri-operative complications, so it is important to tailor the extent and the radicalness of surgery in order to decrease morbidity and mortality potentially derivable from unnecessary procedures. In this regard women with negative nodes derive no benefit from unnecessary lymphadenectomy, but may develop short- and long-term morbidity related to this procedure. Preoperative and intraoperative techniques could be critical tools for tailoring the extent and the radicalness of surgery in the management of women with presumed early endometrial cancer. In this review we will discuss updates in surgical management of early endometrial cancer and also the role of preoperative and intraoperative evaluation of lymph node status in influencing surgical options, with the aim of proposing a management algorithm based on the literature and our experience.
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Affiliation(s)
- Francesca Falcone
- Department of Woman, Child, and General and Specialized Surgery, Second University of Naples, Naples, Italy
| | - Giancarlo Balbi
- Department of Woman, Child, and General and Specialized Surgery, Second University of Naples, Naples, Italy
| | - Luca Di Martino
- Department of Woman, Child, and General and Specialized Surgery, Second University of Naples, Naples, Italy
| | - Flavio Grauso
- Department of Woman, Child, and General and Specialized Surgery, Second University of Naples, Naples, Italy
| | - Maria Elena Salzillo
- Department of Woman, Child, and General and Specialized Surgery, Second University of Naples, Naples, Italy
| | - Enrico Michelino Messalli
- Department of Woman, Child and of General and Special Surgery, Second University of Naples, Naples, Italy
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Pitter MC, Simmonds C, Seshadri-Kreaden U, Hubert HB. The impact of different surgical modalities for hysterectomy on satisfaction and patient reported outcomes. Interact J Med Res 2014; 3:e11. [PMID: 25048103 PMCID: PMC4129130 DOI: 10.2196/ijmr.3160] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 04/30/2014] [Accepted: 05/31/2014] [Indexed: 11/24/2022] Open
Abstract
Background There is an ongoing debate regarding the cost-benefit of different surgical modalities for hysterectomy. Studies have relied primarily on evaluation of clinical outcomes and medical expenses. Thus, a paucity of information on patient-reported outcomes including satisfaction, recovery, and recommendations exists. Objective The objective of this study was to identify differences in patient satisfaction and recommendations by approach to a hysterectomy. Methods We recruited a large, geographically diverse group of women who were members of an online hysterectomy support community. US women who had undergone a benign hysterectomy formed this retrospective study cohort. Self-reported characteristics and experiences were compared by surgical modality using chi-square tests. Outcomes over time were assessed with the Jonkheere-Terpstra trend test. Logistic regression identified independent predictors of patient satisfaction and recommendations. Results There were 6262 women who met the study criteria; 41.74% (2614/6262) underwent an abdominal hysterectomy, 10.64% (666/6262) were vaginal, 27.42% (1717/6262) laparoscopic, 18.94% (1186/6262) robotic, and 1.26% (79/6262) single-incision laparoscopic. Most women were at least college educated (56.37%, 3530/6262), and identified as white, non-Hispanic (83.17%, 5208/6262). Abdominal hysterectomy rates decreased from 68.2% (152/223) to 24.4% (75/307), and minimally invasive surgeries increased from 31.8% (71/223) to 75.6% (232/307) between 2001 or prior years and 2013 (P<.001 all trends). Trends in overall patient satisfaction and recommendations showed significant improvement over time (P<.001).There were differences across the surgical modalities in all patient-reported experiences (ie, satisfaction, time to walking, driving and working, and whether patients would recommend or use the same technique again; P<.001). Significantly better outcomes were evident among women who had vaginal, laparoscopic, and robotic procedures than among those who had an abdominal procedure. However, robotic surgery was the only approach that was an independent predictor of better patient experience; these patients were more satisfied overall (odds ratio [OR] 1.31, 95% CI 1.13-1.51) and on six other satisfaction measures, and more likely to recommend (OR 1.64, 95% CI 1.39-1.94) and choose the same modality again (OR 2.07, 95% CI 1.67-2.57). Abdominal hysterectomy patients were more dissatisfied with outcomes after surgery and less likely to recommend (OR 0.36, 95% CI 0.31-0.40) or choose the same technique again (OR 0.29, 95% CI 0.25-0.33). Quicker return to normal activities and surgery after 2007 also were independently associated with better overall satisfaction, willingness to recommend, and to choose the same surgery again. Conclusions Consistent with other US data, laparoscopic and robotic hysterectomy rates increased over time, with a concomitant decline in abdominal hysterectomy. While inherent shortcomings of this retrospective Web-based study exist, findings show that patient experience was better for each of the major minimally invasive approaches than for abdominal hysterectomy. However, robotic-assisted hysterectomy was the only modality that independently predicted greater satisfaction and willingness to recommend and have the same procedure again.
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Affiliation(s)
- Michael C Pitter
- Newark Beth Israel Medical Center, Minimally Invasive & Gynecologic Robotic Surgery, Newark, NJ, United States.
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Bouwsma EV, Anema JR, Vonk Noordegraaf A, Knol DL, Bosmans JE, Schraffordt Koops SE, van Kesteren PJ, van Baal WM, Lips JP, Emanuel MH, Scholten PC, Mozes A, Adriaanse AH, Brölmann HA, Huirne JA. The cost effectiveness of a tailored, web-based care program to enhance postoperative recovery in gynecologic patients in comparison with usual care: protocol of a stepped wedge cluster randomized controlled trial. JMIR Res Protoc 2014; 3:e30. [PMID: 24943277 PMCID: PMC4090379 DOI: 10.2196/resprot.3236] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 05/21/2014] [Indexed: 11/13/2022] Open
Abstract
Background The length of recovery after benign gynecological surgery and return to work frequently exceeds the period that is recommended or expected by specialists. A prolonged recovery is associated with a poorer quality of life. In addition, costs due to prolonged sick leave following gynecological surgery cause a significant financial burden on society. Objective The objective of our study was to present the protocol of a stepped wedge cluster randomized controlled trial to evaluate the cost effectiveness of a new care program for patients undergoing hysterectomy and/or adnexal surgery for benign disease, compared to the usual care. Methods The care program under study, designed to improve convalescence and to prevent delayed return to work, targets two levels. At the hospital level, guidelines will be distributed among clinical staff in order to stimulate evidence-based patient education. At the patient level, additional perioperative guidance is provided by means of an eHealth intervention, equipping patients with tailored convalescence advice, and an occupational intervention is available for those patients at risk of prolonged sick leave. Due to the stepped wedge design of the trial, the care program will be sequentially rolled out among the 9 participating hospitals, from which the patients are recruited. Eligible for this study are employed women, 18-65 years of age, who are scheduled for hysterectomy and/or laparoscopic adnexal surgery. The primary outcome is full sustainable return to work. The secondary outcomes include general recovery, quality of life, self-efficacy, coping, and pain. The data will be collected by means of self-reported electronic questionnaires before surgery and at 2, 6, 12, 26, and 52 weeks after surgery. Sick leave and cost data are measured by monthly sick leave calendars, and cost diaries during the 12 month follow-up period. The economic evaluation will be performed from the societal perspective. All statistical analyses will be conducted according to the intention-to-treat principle. Results The enrollment of the patients started October 2011. The follow-up period will be completed in August 2014. Data cleaning or analysis has not begun as of this article’s submission. Conclusions We hypothesize the care program to be effective by means of improving convalescence and reducing costs associated with productivity losses following gynecological surgery. The results of this study will enable health care policy makers to decide about future implementation of this care program on a broad scale. Trial Registration Netherlands Trial Register: NTR2933; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2933 (Archived by WebCite at http://www.webcitation.org/6Q7exPG84).
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Affiliation(s)
- Esther Va Bouwsma
- Department of Obstetrics and Gynecology, VU University Medical Center, Amsterdam, Netherlands
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Hobson DT, Imudia AN, Al-Safi ZA, Shade G, Diamond MP, Awonuga AO. Prior Cesarean Delivery and Risk of Conversion to Laparotomy During Laparoscopic Hysterectomy. J Gynecol Surg 2013. [DOI: 10.1089/gyn.2013.0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Deslyn T.G. Hobson
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine/Detroit Medical Center, Detroit, MI
| | - Anthony N. Imudia
- Massachusetts General Hospital Fertility Center, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital/Harvard Medical School, Boston, MA
| | - Zain A. Al-Safi
- Division of Reproductive Endocrinology and Infertility, University of Colorado Denver, Aurora, CO
| | - George Shade
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine/Detroit Medical Center, Detroit, MI
| | - Michael P. Diamond
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine/Detroit Medical Center, Detroit, MI
- Division of Reproductive Endocrinology and Infertility, Wayne State University School of Medicine/Detroit Medical Center, Detroit, MI
| | - Awoniyi O. Awonuga
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine/Detroit Medical Center, Detroit, MI
- Division of Reproductive Endocrinology and Infertility, Wayne State University School of Medicine/Detroit Medical Center, Detroit, MI
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Munro MG. Economics and energy sources. J Minim Invasive Gynecol 2013; 20:319-27. [PMID: 23659752 DOI: 10.1016/j.jmig.2013.02.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Accepted: 02/01/2013] [Indexed: 10/26/2022]
Abstract
Energy-based instrumentation has not only facilitated the rapid adoption of laparoscopic surgery, but could be considered essential for the completion of abdominal and pelvic procedures under endoscopic guidance. For decades, relatively simple and generic reusable monopolar and bipolar systems were the only options available. More recently, the available options for energy-based surgical instrumentation have become more crowded with the introduction of ultrasound-based cutting and sealing instruments and proprietary, impedance monitoring radiofrequency coagulation devices. Such instrumentation is presented as being easier to use as well as providing greater safety and efficacy. However, these new instruments typically require the expenditure of capital for proprietary energy generators and are usually designed to be for single use, a circumstance that increases per case costs, a circumstance that begs the question of value. Do the additional costs expended for the more expensive devices translate into reduced complications, faster operating time, or even wider access to minimally invasive procedures because they enable more surgeons to offer the service? Herein is explored the complex economic issues associated with the use of energy-based surgical devices as they apply to minimal access surgery in general and to laparoscopic procedures specifically.
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Affiliation(s)
- Malcolm G Munro
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, CA 91356, USA.
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Twijnstra ARH, Blikkendaal MD, van Zwet EW, Jansen FW. Clinical relevance of conversion rate and its evaluation in laparoscopic hysterectomy. J Minim Invasive Gynecol 2013; 20:64-72. [PMID: 23312244 DOI: 10.1016/j.jmig.2012.09.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Revised: 09/18/2012] [Accepted: 09/22/2012] [Indexed: 10/27/2022]
Abstract
STUDY OBJECTIVES To estimate the current conversion rate in laparoscopic hysterectomy (LH); to estimate the influence of patient, procedure, and performer characteristics on conversion; and to hypothesize the extent to which conversion rate can act as a means of evaluation in LH. DESIGN Prospective cohort study (Canadian Task Force classification II-2). SETTING The study included 79 gynecologists representing 42 hospitals throughout the Netherlands. This reflects 75% of all gynecologists performing LH in the Netherlands, and 68% of all hospitals. PATIENTS Data from 1534 LH procedures were collected between 2008 and 2010. INTERVENTION All participants in the nationwide LapTop registration study recorded each consecutive LH they performed during 1 year. MEASUREMENTS AND MAIN RESULTS Conversion rate and odds ratios (OR) of risk factors for conversion were calculated. Conversions were described as reactive or strategic. The literature reported a conversion rate for LH of 0% to 19% (mean, 3.5%). In our cohort, 70 LH procedures (4.6%) were converted. Using a mixed-effects logistic regression model, we estimated independent risk factors for conversion. Body mass index (BMI) (p = .002), uterus weight (p < .001), type of LH (p = .004), and age (p = .02) had a significant influence on conversion. The risk of conversion was increased at BMI >35 (OR, 6.53; p < .001), age >65 years (OR, 6.97; p = .007), and uterus weight 200 to 500 g (OR, 4.05; p < .001) and especially >500 g (OR, 30.90; p < .001). A variation that was not explained by the covariates included in our model was identified and referred to as the "surgical skills factor" (average OR, 2.79; p = .001). CONCLUSION Use of estimated risk factors (BMI, age, uterus weight, and surgical skills) provides better insight into the risk of conversion. Conversion rate can be used as a means of evaluation to ensure better outcomes of LH in future patients.
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Goolab BD. Vaginal hysterectomy and relative merits over abdominal and laparoscopically assisted hysterectomy. Best Pract Res Clin Obstet Gynaecol 2013; 27:393-413. [DOI: 10.1016/j.bpobgyn.2013.01.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 01/31/2013] [Indexed: 10/26/2022]
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Wright KN, Jonsdottir GM, Jorgensen S, Shah N, Einarsson JI. Costs and outcomes of abdominal, vaginal, laparoscopic and robotic hysterectomies. JSLS 2013; 16:519-24. [PMID: 23484557 PMCID: PMC3558885 DOI: 10.4293/108680812x13462882736736] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Complication rates did not vary significantly among minimally invasive methods of hysterectomy; however, patient costs were significantly influenced by the technique used for hysterectomy. Background and Objectives: To estimate the incidence of operative complications and compare operative cost and overall cost of different methods of benign hysterectomy including abdominal, vaginal, laparoscopic, and robotic techniques. Methods: We performed a retrospective cohort analysis (Canadian Task Force classification II-2) of all patients who underwent a hysterectomy for benign reasons in 2009 at a single urban academic tertiary care center using the χ2 test and Student t test. A multivariate regression analysis was also performed for predictors of costs. Cost data were gathered from the hospital's billing system; the remainder of data was extracted from patient's medical records. Results: In 2009, 688 patients underwent a benign hysterectomy; 185 (26.9%) hysterectomies were abdominal, 135 (19.6%) vaginal, 352 (51.5%) laparoscopic, and 14 (2.0%) robotic. The rate of intraoperative complication was 1.7% for abdominal, 0.8% for vaginal, 0.3% for laparoscopic, and 0 for robotic. Mean total patient costs were $43,622 for abdominal, $31,934 for vaginal, $38,312 for laparoscopic, and $49,526 for robotic hysterectomies. Costs were significantly influenced by method of hysterectomy, operative time, and length of stay. Conclusion: Though complication rates did not vary significantly among minimally invasive methods of hysterectomy, patient costs were significantly influenced by the method of hysterectomy.
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Affiliation(s)
- Kelly N Wright
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA.
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Rhou YJJ, Pather S, Loadsman JA, Campbell N, Philp S, Carter J. Direct hospital costs of total laparoscopic hysterectomy compared with fast-track open hysterectomy at a tertiary hospital: a retrospective case-controlled study. Aust N Z J Obstet Gynaecol 2013; 55:584-7. [PMID: 23634987 DOI: 10.1111/ajo.12093] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Accepted: 03/21/2013] [Indexed: 11/29/2022]
Abstract
AIMS To assess the direct intraoperative and postoperative costs in women undergoing total laparoscopic hysterectomy and fast-track open hysterectomy. METHODS A retrospective review of the direct hospital-related costs in a matched cohort of women undergoing total laparoscopic hysterectomy (TLH) and fast-track open hysterectomy (FTOH) at a tertiary hospital. All costs were calculated, including the cost of advanced high-energy laparoscopic devices. The effect of the learning curve on cost in laparoscopic hysterectomy was also assessed, as was the hospital case-weighted cost, which was compared with the actual cost. RESULTS Fifty women were included in each arm of the study. TLH had a higher intraoperative cost, but a lower postoperative cost than FTOH (AUD$3877 vs AUD$2776 P < 0.001, AUD$3965 vs AUD$6233 P < 0.001). The total cost of TLH was not different from FTOH (AUD$7842 vs AUD$9009 P = 0.068) and after a learning curve; TLH cost less than FTOH (AUD$6797 vs AUD$8647, P < 0.001). The use of high-energy devices did not impact on the cost benefit of TLH, and hospital case-weight-based funding correlated poorly with actual cost. CONCLUSION Despite the use of fast-track recovery protocols, the cost of TLH is no different to FTOH and after a learning curve is cheaper than open hysterectomy. Judicious use of advanced energy devices does not impact on the cost, and hospital case-weight-based funding model in our hospital is inaccurate when compared to directly calculated hospital costs.
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Affiliation(s)
- Yoon J J Rhou
- The Sydney Gynaecologic Oncology Group, Sydney Cancer Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Selvan Pather
- The Sydney Gynaecologic Oncology Group, Sydney Cancer Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - John A Loadsman
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Neil Campbell
- Department of Obstetrics and Gynaecology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Shannon Philp
- The Sydney Gynaecologic Oncology Group, Sydney Cancer Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Sydney School of Nursing University of Sydney, Sydney, New South Wales, Australia
| | - Jonathan Carter
- The Sydney Gynaecologic Oncology Group, Sydney Cancer Centre, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Taş B, Donatsky AM, Gögenur I. Techniques to reduce shoulder pain after laparoscopic surgery for benign gynaecological disease: a systematic review. ACTA ACUST UNITED AC 2013. [DOI: 10.1007/s10397-013-0791-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Wodlin NB, Nilsson L. The development of fast-track principles in gynecological surgery. Acta Obstet Gynecol Scand 2012; 92:17-27. [PMID: 22880948 DOI: 10.1111/j.1600-0412.2012.01525.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Fast-track is a multimodal strategy aimed at reducing the physiological burden of surgery to achieve an enhanced postoperative recovery. The strategy combines unimodal evidence-based interventions in the areas of preoperative preparation, anesthesia, surgical factors and postoperative care. The advantages of fast-track most likely extend to gynecology, although so far have scarcely been reported. This review summarizes current evidence concerning use of fast-track in general and in gynecological surgery. The main findings of this review are that there are benefits within elective gynecological surgery, but studies of quality of life, patient satisfaction and health economics in elective surgery are needed. Studies of fast-track within the field of non-elective gynecological surgery are lacking. Widespread education is needed to improve the rate of implementation of fast-track. Close involvement of the entire surgical team is imperative to ensure a structured perioperative care aiming for enhanced postoperative recovery.
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Affiliation(s)
- Ninnie Borendal Wodlin
- Division of Obstetrics and Gynecology, Department of Clinical and Experimental Medicine, Faculty of Health Sciences, Linköping University, Linköping, Sweden.
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Ghosh D, Wipplinger P, Byrne DL. Can total laparoscopic hysterectomy replace total abdominal hysterectomy? A 5-year prospective cohort study of a single surgeon's experience in an unselected population. ACTA ACUST UNITED AC 2012. [DOI: 10.1007/s10397-012-0754-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Acholonu UC, Chang-Jackson SCR, Radjabi AR, Nezhat FR. Laparoscopy for the Management of Early-Stage Endometrial Cancer: From Experimental to Standard of Care. J Minim Invasive Gynecol 2012; 19:434-42. [DOI: 10.1016/j.jmig.2012.02.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Revised: 02/16/2012] [Accepted: 02/25/2012] [Indexed: 10/28/2022]
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Janssen PF, Brölmann HAM, van Kesteren PJM, Bongers MY, Thurkow AL, Heymans MW, Huirne JAF. Perioperative outcomes using LigaSure™ compared to conventional bipolar instruments in laparoscopic salpingo-oophorectomy: a randomized controlled trial. Surg Endosc 2012; 26:2884-91. [PMID: 22538682 DOI: 10.1007/s00464-012-2274-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 03/23/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND The aim of this study was to compare the effects of LigaSure™ versus conventional bipolar techniques on operating time and blood loss during laparoscopic salpingo-oophorectomy in a randomized controlled trial. METHODS In three teaching hospitals, 100 women undergoing a laparoscopic salpingo-oophorectomy were randomized for LigaSure or conventional bipolar instruments. Primary outcome was operating time (from initial skin incision to removal of the specimen). Secondary outcome measures were total operating time (from initial skin incision to skin closure), time to dissect the ovarian and infundibulopelvic ligaments, intraoperative blood loss, and subjective judgment of the instrument used. RESULTS There were no differences in operating time and total operating time using LigaSure versus conventional bipolar instruments: 41.0 vs. 39.2 min (p = 0.78; 95 % CI = -10.9 to 14.5) and 54.6 vs. 58.6 min (p = 0.46; 95 % CI = -14.8 to 6.8), respectively. The mean blood loss using LigaSure versus conventional bipolar instruments was 38 vs. 33 mL (p = 0.73; 95 % CI = -22.7 to 32.2). Various subjective efficacy and instrument handling parameters of the two instruments varied among participating centers. CONCLUSION There were no significant differences in operating time and blood loss with the use of LigaSure compared to conventional bipolar instruments during laparoscopic salpingo-oophorectomy, even after correction for potential confounders.
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Affiliation(s)
- Petra F Janssen
- Department of Obstetrics and Gynecology, VU University Medical Center, De Boelelaan 1117, 1181 HV, Amsterdam, The Netherlands.
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Lu Z, Yi X, Feng W, Ding J, Xu H, Zhou X, Hua K. Cost-benefit analysis of laparoscopic surgery versus laparotomy for patients with endometrioid endometrial cancer: experience from an institute in China. J Obstet Gynaecol Res 2012; 38:1011-7. [PMID: 22487546 DOI: 10.1111/j.1447-0756.2011.01820.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To compare the clinical outcomes and associated costs between laparoscopic and abdominal surgery for patients with endometrioid endometrial cancer. METHODS From 2003 to 2008, 115 patients who underwent laparoscopically-assisted surgery for endometrioid endometrial cancers were enrolled in this retrospective study. Another 123 patients who had abdominal surgery for the same histological type of endometrial cancer were included as the control group. The clinico-pathological variables, surgical outcome, costs, death and case recurrence of the two groups were compared. RESULTS There was no difference in the patients' age, body mass index, FIGO stage, histological grade or surgical types between the two groups. The patients in the laparoscopy group had less blood loss (P = 0.010), a shorter hospital stay (P < 0.001), less postoperative pain (P < 0.001) and lower complication rates (P < 0.001) than those treated by laparotomy. The total costs in the laparoscopy group were higher than that in the laparotomy group ($2073 vs $1638, P < 0.001). Patients in the laparoscopy group returned to usual activity more quickly (P = 0.001) and went back to work earlier (P = 0.013) than those in laparotomy group. With a median follow-up of 42 months for the laparoscopy group and 40 months for the laparotomy group, there was no significant difference in the number of cases with respect to death (P = 1.000) or recurrence (P = 1.000). CONCLUSIONS Laparoscopically-assisted surgery is as effective as the laparotomy approach for the treatment of early-stage and advanced-stage endometrial cancer. The relatively higher cost of the laparoscopic surgery may be compensated by its benefits. In developing countries such as China, laparoscopically-assisted surgery is also an attractive alternative for selected patients with endometrial cancer.
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Affiliation(s)
- Zhiying Lu
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, 419 Fang Xie Road, Shanghai, China
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Hirschelmann A, De Wilde RL. Plastic and reconstructive uterus operations by minimally invasive surgery? A review on myomectomy. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2012; 1:Doc09. [PMID: 26504693 PMCID: PMC4582479 DOI: 10.3205/iprs000009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Plastic and reconstructive uterus operations are performed in congenital uterine anomalies or benign uterine conditions. Congenital uterine anomalies are relatively rare diseases with various approaches for surgical treatment. Therefore, to address the question of the usefulness of a minimally invasive approach in plastic uterus operations, the most common uterine condition which requires reconstructive surgery, namely myomectomy, is discussed. METHOD Searches were conducted in PubMed and The Cochrane Library to identify relevant literature. FINDINGS Compared with myomectomy by laparotomy and minilaparotomy, laparoscopic myomectomy is associated with improved short-term outcomes. Laparoscopy is further associated with less adhesion formation. Pregnancy rates after myomectomy in symptomatic patients might be higher after laparoscopy than after laparotomy. Although uterine ruptures following laparoscopic myomectomy are described in the literature, it seems to be a rare event. Concerning the recurrence, there is evidence that rates are similar after laparoscopy and laparotomy. CONCLUSION Myomectomy by laparoscopy has several advantages over abdominal myomectomy (by conventional laparotomy and minilaparotomy) and should be the standard procedure. Despite the advantages of laparoscopy, abdominal myomectomy is still a frequently performed procedure. Lack of training in advanced laparoscopic procedures hampers the wide-spread use of laparoscopic myomectomy. Due to the advantages of laparoscopic surgery, efforts should be made to implement this procedure into daily practice. To provide the best care, physicians should offer patients the opportunity of a laparoscopic treatment of myomas.
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Affiliation(s)
- Anja Hirschelmann
- Pius-Hospital Oldenburg, Klinik für Frauenheilkunde, Geburtshilfe und Gynäkologische Onkologie, Oldenburg, Germany
| | - Rudy Leon De Wilde
- Pius-Hospital Oldenburg, Klinik für Frauenheilkunde, Geburtshilfe und Gynäkologische Onkologie, Oldenburg, Germany
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