Continuous epidural infusion in gynecologic oncology patients undergoing exploratory laparotomy: The new standard for decreased postoperative pain and opioid use.

OBJECTIVE: To compare the incidence of postoperative complications and opioid pain medication usage in gynecologic oncology patients who did and did not receive an epidural prior to undergoing exploratory laparotomy. METHODS: Retrospective cohort study of all patients undergoing exploratory laparotomy with the gynecologic oncology division at Washington University in St Louis between January 2012 and October 2015. Data on demographics, pathology, postoperative pain and opioid use, and incidence of postoperative complications were collected. RESULTS: Five hundred and sixty-one patients underwent laparotomy, 305 with an epidural and 256 without. Patients with an epidural used significantly less hydromorphone in the post-anesthesia care unit (PACU) (p = 0.003) and on postoperative day (POD)#1 (p = 0.05), less total opioids on POD#0 (p < 0.01), and more non-opioid pain medication on POD#1-3 (p < 0.01). Patients with an epidural had lower pain scores in the PACU (p = 0.01), on POD#0 (p < 0.01), POD#1 (p < 0.01), and POD#3 (p = 0.03). Patients with epidurals had shorter hospital length of stay (p < 0.01), no difference in hospital readmission or incidence of venous thromboembolism up to 90 days postoperatively, longer duration of Foley catheter (20.4 vs 10.3 h, p = 0.02) with no difference in postoperative urinary tract infection, higher incidence of postoperative hypotension (63% vs 36.3%, p < 0.01), and lower incidence of wound complications (5% vs 14.1%, p < 0.01). CONCLUSIONS: Perioperative epidurals used in patients undergoing major abdominal surgery correlate with decreased postoperative opioid use, increased use of non-opioid pain medications, and improved pain relief postoperatively with acceptable postoperative risks and should be standard of care for these patients.

Benefit of combination chemotherapy and radiation stratified by grade of stage IIIC endometrial cancer.

OBJECTIVE: The optimal strategy for adjuvant therapy in stage IIIC endometrial cancer has not been determined. Our aim was to evaluate survival benefit of different treatments and to investigate if benefit varied by histologic grade. METHODS: We identified 199 patients with stage IIIC endometrial cancer from 2000 to 2012 through the Siteman Cancer Center registry. All patients underwent surgical staging followed by no adjuvant therapy (NAT), radiation (RT), chemotherapy (CT) or chemoradiation (CRT). The association between adjuvant treatment and overall survival was explored using Kaplan-Meier plots and multivariable Cox regression analysis. Multivariable analysis was stratified by low- or high-grade to explore the interaction between grade and treatment. RESULTS: Most patients received CRT (50.3%) followed by CT (23.1%), RT (16.1%) and NAT (10.5%). Survival after CRT was superior to NAT (p<0.001), RT (p=0.010) and CT (p<0.001). After adjusting for covariates, treatment with RT, CT and CRT led to a 57% (p=0.024), 62% (p=0.003) and 83% (p<0.001) reduction in risk of death compared to NAT, respectively. With CRT as the reference, the adjusted hazard of death was higher with NAT (5.94, p<0.001), RT (2.56, p=0.009) and CT (2.24, p=0.004). Stratifying by grade, RT and CRT led to a 67% (p=0.039) and 85% (p<0.001) reduction in death, compared to NAT in low-grade patients. CT and CRT led to a 72% (p=0.003) and 83% (p<0.001) reduction in death, compared to NAT in high-grade patients. CONCLUSIONS: Our findings suggest that CRT should be the preferred adjuvant treatment strategy for patients with stage IIIC endometrial cancer.