Bowel Endometriosis Excision: Approaches and Outcomes Including Hand Sewing of Discoid Excision.

STUDY OBJECTIVE: To examine the outcomes of surgery performed for bowel endometriosis including shaving, discoid resections with hand-sewn closure, and segmental resection. DESIGN: Retrospective cohort study. SETTING: Large academic hospital. PATIENTS: All patients with bowel wall endometriosis who underwent surgical excision with the Division of Minimally Invasive Gynecologic Surgery between 2009 and 2022. INTERVENTIONS: No interventions administered. MEASUREMENTS AND MAIN RESULTS: From 2009 to 2022, a total of 112 patients underwent laparoscopic excision of endometriosis involving the rectum. From this cohort, 82 underwent shaving, 23 underwent discoid excision, and 7 had segmental bowel resection. The discoid excisions were closed in multiple layers with hand sewing and were not closed with a staple device. Average lesion size on preoperative imaging was 20.9 mm in the shave group, 22.5 mm in the discoid group, and 38.5 mm in the segmental group. Complication requiring reoperation for anastomotic leak occurred in 3 cases (3.66%) of the shave group and 1 case (4.35%) of the discoid excision group, but did not occur in any of the segmental resections. The number of layers of closure and type of suture used did not appear to have an effect on complication rate, however, this study was not powered to detect a meaningful difference. CONCLUSION: Our data shows a similar rate of anastomotic leak complication for each closure type as that reported in the literature (2.2%, 9.7%, and 9.9% reported for shave, discoid and segmental resection, respectively). While our study is underpowered, these findings support that hand sewing for discoid excision is a safe and reasonable alternative to circular stapler closures and can be considered with an experienced surgeon. Further study is warranted to confirm safety and explore potential cost savings associated with this technique as well as applications in areas with less resources available.

Disparities in access to minimally invasive surgery for inflammatory bowel disease and outcomes by insurance status: analysis of the 2015 to 2019 National Inpatient Sample.

INTRODUCTION: Despite being the preferred modality for treatment of colorectal cancer and diverticular disease, minimally invasive surgery (MIS) has been adopted slowly for treatment of inflammatory bowel disease (IBD) due to its technical challenges. The present study aims to assess the disparities in use of MIS for patients with IBD. METHODS: A retrospective analysis of the National Inpatient Sample (NIS) database from October 2015 to December 2019 was conducted. Patients < 65 years of age were stratified by either private insurance or Medicaid. The primary outcome was access to MIS and secondary outcomes were in-hospital mortality, complications, length of stay (LOS), and total admission cost. Univariate and multivariate regression was utilized to determine the association between insurance status and outcomes. RESULTS: The NIS sample population included 7866 patients with private insurance and 1689 with Medicaid. Medicaid patients had lower odds of receiving MIS than private insurance patients (OR 0.85, 95% CI [0.74-0.97], p = 0.017), and experienced more postoperative genitourinary complications (OR 1.36, 95% CI [1.08-1.71], p = 0.009). In addition, LOS was longer by 1.76 days (p < 0.001) and the total cost was higher by $5043 USD (p < 0.001) in the Medicaid group. Independent predictors of receiving MIS were age < 40 years old, female sex, highest income quartile, diagnosis of ulcerative colitis, elective admission, and care at teaching hospitals. CONCLUSIONS: Patients with Medicaid are less likely to receive MIS, have longer lengths of stay, and incur higher costs for the surgical management of their IBD. Further investigations into disparities in inflammatory bowel disease care for Medicaid patients are warranted.

Keep your attention closer to the ureters: Ureterolysis in deep endometriosis surgery.

Endometriosis surgery involving the ureter poses significant challenges requiring meticulous surgical techniques and vigilant postoperative care. This chapter addresses key aspects of ureterolysis techniques, intraoperative management of ureteral injuries, and postoperative care in the context of endometriosis surgery. Ureterolysis methods aim to isolate and mobilize the ureter while preserving its vascularity. Cold instruments and careful dissection are recommended to prevent thermal injury during surgery. Intraoperative tools such as indocyanine green (ICG) show promise in assessing for vascular compromise. Over half of ureteral injuries are detected postoperatively, necessitating a high index of suspicion. Optimal postoperative care in the case of ureteral injury involves Foley catheterization for decompression, ureteral stenting, and meticulous follow-ups to monitor healing and renal function. While advances have been made in surgical techniques and diagnostic tools, gaps persist in preoperative imaging optimization and predictive models for identifying at-risk patients. This chapter aims to bridge existing knowledge gaps, optimize surgical practices, and enhance the overall care and outcomes of patients undergoing endometriosis surgery involving the ureter.

Examining the effect of unintended pregnancy on health utility using four measures.

OBJECTIVES: We measured women's preferences for avoiding an unintended pregnancy. We determined if young age (<25) was associated with lowest utility with an unintended pregnancy. STUDY DESIGN: We conducted a cross sectional study of women presenting for hormonal contraception who did not desire a pregnancy. We used four techniques to elicit health prefences and calculate utilities for an unintended pregnancy: visual analog scale, and willingness to pay, time-tradeoff (TTO), and standard gamble. We dichotomized each measure to define lowest utility for each measure. We used predicted probabilities and multivariable logistic regression to estimate the association between age (≤25 vs ≥26 y) and lowest utility with an unintended pregnancy. RESULTS: Our sample included 419 participants from four states. We found that younger age (≤25) was positively associated with reporting the lowest utility for unintended pregnancy. In absolute terms, with the visual analog scale, the probability that a woman 25 years or younger would have lower preference for an unintended pregnancy was 26.8% (95% CI 20.4-33.2%) versus (21.7% (95% CI 14.3-29.0%). Using the willingness to pay, the probability of the younger group having lower preference was 84.9% (CI 80.3-89.4%) compared to 57.3% (CI 49.3-65.3). With the TTO, Women 25 years old and younger had a 78.3% probability (CI 72.6-84.0%) of low utility on the TTO vs 48.9% (CI 40.9-56.9%) in the older group. With standard gamble, younger women had a 47.0% probability (CI 36.8-50.6%) versus 18.0% (CI 14.7-27.5%). CONCLUSIONS: Women of all ages report a decrease in health utility with unintended pregnancy. This decrease in health utility is greater among young women (age <25). IMPLICATIONS: Health utilities for unintended pregnancy can be used to guide cost effectiveness research and health policy.

Increased rates of adverse perinatal outcomes in women with gestational diabetes and depression.

OBJECTIVE: We sought to examine the impact of depression on adverse perinatal outcomes in women with Gestational Diabetes Mellitus (GDM). METHODS: We performed a retrospective cohort study comparing the rates of perinatal complications among singleton, nonanomalous births to women with GDM and the diagnosis of depression compared to GDM women without depression between 2007 and 2011 in California. Perinatal outcomes were analyzed using chi-square and multivariable logistic regression to compare frequencies of characteristics and outcomes and to determine the strength of association of depression and adverse perinatal outcomes among women with GDM. Statistical comparisons with a p-value of less than .05 and 95% CI that did not cross the null were considered statistically significant. RESULTS: Among the cohort of 170,572 women with GDM, 2090 (1.22%) were diagnosed with antenatal depression. Women with GDM and depression had significantly higher rates of preeclampsia (adjusted Odds Ratio [aOR] 1.28, 95% CI 1.11-1.49) and gestational hypertension (aOR 1.23, 95% CI 1.05-1.44). Women with GDM and depression also had higher rates of preterm delivery at <37, and <34 weeks gestational age (aOR 1.33, 95% CI 1.18-1.50 and 1.36, 95% CI 1.15-1.61, respectively). CONCLUSION: Women with GDM and a diagnosis of depression have higher rates of adverse perinatal outcomes than women with GDM alone. Identifying and managing depression among women with GDM has the potential to improve the care and health of this high-risk population.