Robotic Hysterectomy for Endometrial Cancer in Obese Patients With Comorbidities: Evaluating Postoperative Complications.

OBJECTIVES: The objective of this study is to determine (1) if there is a relationship between increasing body mass index (BMI) and postoperative complications in patients undergoing robotic hysterectomy for endometrial cancer and (2) if there are additional patient characteristics, specifically preoperative comorbidities, which increase the risk of postoperative complication METHODS: A retrospective chart review was conducted on women who underwent a robotic staging surgery for endometrial cancer from 2006 to 2012. Basic demographics and preoperative and postoperative complications were extracted from the medical records. Obesity was divided into 4 categories, and complication rates were compared across these subgroups. Patients were also divided by the number of comorbidities and compared. RESULTS: The cohort included 543 patients. The BMI ranged from 17.3 to 69.5 kg/m. Three hundred eighty patients (70%) were obese (BMI >30 kg.m). One hundred ninety patients (35%) had no comorbidities other than obesity, and 180 patients (33%) had only 1 comorbidity other than obesity (Table 1).Postoperative complications occurred in 102 (18.7%) of the patients. Severe postoperative complications, including intensive care unit admission, reintubation, reoperation, and perioperative death, occurred in 14 patients (2.6%). Of the nonobese patients, 27 (16.5%) had postoperative complications; of the obese patients, 75 (19.7%) had a complication (P = 0.38). In patients with no comorbidities, 16.3% had a complication; 18% of patients with 1 to 2 comorbidities had a complication, and 28% of patients with 3 or more comorbidities had a complication (P = 0.08). CONCLUSIONS: The postoperative complication rate based on BMI or number of comorbidities was not statistically significant, but patients with greater number of comorbidities had an increased rate of postoperative complications. Patients with certain comorbidities, cardiac and renal specifically, had the highest rates of postoperative complications.

Predicting inpatient stay lasting 2 midnights or longer after robotic surgery for endometrial cancer.

OBJECTIVE: To estimate the rate of inpatient stay and the factors predicting inpatient status after robotic surgery for endometrial cancer following the change in the Medicare definition of "inpatient" to include hospitalization spanning 2 midnights. DESIGN: Retrospective chart review (Canadian Task Force classification II-1). SETTING: Academic hospital. PATIENTS: All patients (n = 395) with endometrial cancer who underwent robotic surgical management between 2006 and 2010. INTERVENTION: The outpatient stay group with hospitalization spanning 1 midnight was compared with the inpatient stay group with hospitalization spanning 2 midnights or longer through estimation of the adjusted relative risk (aRR) for various characteristics of interest. RESULTS: Ninety-six of 395 patients (24.3%) stayed at least 2 midnights and thus were deemed inpatients. Clinical factors associated with inpatient stay were increasing age, history of myocardial infarction (aRR, 2.0; 95% confidence interval [CI], 1.0-3.7), surgery start time at or after 12 noon (aRR, 1.7; 95% CI, 1.2-2.4), perioperative blood transfusion (aRR, 3.2; 95% CI, 2.3-4.5), and surgery performed in the year 2010 (aRR, 0.5; 95% CI, 0.3-0.7). Age ≥ 60 years was associated with at least a 2-fold adjusted risk of prolonged hospitalization. Body mass index, other medical comorbidities, operative duration, estimated blood loss, and performance of lymphadenectomy or additional surgical procedures were not identified as significant risk factors. CONCLUSION: Approximately 75% of the patients undergoing robotic surgery for endometrial cancer were discharged as outpatients. Recognition of factors predicting inpatient stay can improve hospital resource allocation and throughput in women undergoing robotic surgery for endometrial cancer.

Reducing readmissions after robotic surgical management of endometrial cancer: a potential for improved quality care.

OBJECTIVE: To describe readmission patterns after robotic surgery for endometrial cancer and identify risk factors for readmission within 90 days of discharge. METHODS: Patients with endometrial cancer who underwent robotic surgical management at an academic institution from 2006 to 2010 were identified. Patient characteristics, intraoperative data, and postoperative complications were analyzed. Student's t-test and Fisher's exact test were used to compare patients readmitted within 90 days to those who were not. RESULTS: Three hundred ninety-five patients were included. Thirty (7.6%) were readmitted within 90 days of surgical discharge. Length of stay greater than one day (40.0% vs. 23.0%, p=0.04) and postoperative complication (63.3% vs. 13.4%, p<0.01) were associated with readmission. The median interval to readmission was 9.5 days and median duration of subsequent hospitalization was 2.5 days. Fever (31.3%) and workup for vaginal drainage (25.0%) were the most common reasons for readmission. Only 2 of the 10 patients readmitted with fever had culture-proven infection, and no patients readmitted for vaginal drainage had a confirmed urinary tract injury. Of the 30 patients readmitted, 5 required a second operation - 3 for vaginal cuff dehiscence and 2 for port site hernia. CONCLUSIONS: Robotic surgery for endometrial cancer was associated with a 7.6% readmission rate. The most common reasons for readmission, fever and evaluation for urinary tract injury, were frequently not associated with severe illness. This supports additional education to consider raising the threshold for readmission by using more widespread outpatient evaluation for the potential complications of robotic endometrial cancer surgery.

A Pilot Lifestyle Behavior Intervention for Overweight or Obese Pregnant Women: Results and Process Evaluation.

Introduction: This paper presents a pilot lifestyle behavior intervention effect on gestational weight gain and maternal and neonatal outcomes and intervention acceptability. Materials and Methods: Overweight or obese pregnant participants (N = 70) were randomized to the intervention or usual care group. The 20-week intervention integrated Hope theory and goal-oriented episodic future thinking (GoEFT) to prevent excessive gestational weight gain through stress and emotion management, healthy eating, and physical activity. Intervention participants completed a weekly web intervention module with 2 parts (I and II) and joined individual health coaching sessions (10 sessions). The primary outcome was gestational weight gain (GWG). Secondary outcomes included maternal and neonatal outcomes. Data were collected at 3 time points: baseline (< 17 weeks gestation, T1), 24-27 weeks gestation (T2), and 35-37 weeks gestation (T3). Intervention participants completed a semi-structured interview to evaluate the intervention. We compared GWG at T2 and T3 with T1 for intervention and usual care groups using t-tests and conducted content analysis to identify common themes for intervention acceptability. Results: There were no significant group differences in GWG at T2 and T3. Maternal and neonatal outcomes were similar between groups. Common themes for intervention acceptability were disked web Part I intervention presented in text, the need for choosing a weekly intervention topic, raising awareness through GoEFT and self-evaluation, increased motivation through GoEFT, and usefulness of pre-written goals and goal progress evaluation. Conclusions: Results of process evaluation are helpful for researchers to design a lifestyle intervention to prevent excessive gestational weight gain.

Dietary Intake of Micronutrients and Essential Fatty Acids among Overweight or Obese Pregnant Women during Early Pregnancy.

Background: Dietary intake of micronutrients and essential fatty acids in overweight or obese pregnant women during early pregnancy is unknown. We investigated the proportion of pregnant women meeting recommendations for dietary intake of micronutrients and essential fatty acids and compared stress and depressive symptoms between those meeting and below recommendations. Methods: Participants (N = 70) were overweight or obese pregnant women ≤16 weeks gestation. They completed two 24-hour dietary recalls and online surveys measuring stress and depressive symptoms. Micronutrients of interest included B vitamins, choline, and trace minerals (calcium, magnesium, selenium, and zinc). Essential fatty acids were docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). Results: Low proportions of participants met recommendations for choline (21.4%) and folate (24.3%). Yet, the proportion of women meeting recommendations for other B vitamins and trace minerals were much better. Less than 9.0% of participants met recommendations for essential fatty acids. Compared with those below recommendations for B3 and selenium, participants meeting recommendations had significantly fewer depressive symptoms. Conclusions: Low proportions of overweight or obese pregnant participants met dietary intake recommendations for micronutrients and essential fatty acids.

Mediation by Executive Functions in the Associations Between Perceived Stress, Prenatal Distress, Emotional Control, and Dietary Intake in Overweight or Obese Pregnant Women.

Background: The study explored potential mediation by executive functions (behavioral regulation index [BRI] and metacognition index [MI]) in association between perceived stress, prenatal distress, emotional control, and dietary intake (total calorie, total fat, added sugar, fruits, and vegetables). Methods: 70 overweight or obese pregnant women completed validated online surveys and two 24-hour dietary recalls. Path analyses were performed. Results: Increased perceived stress was associated with increased BRI both directly (p < 0.001) and indirectly through increased MI (perceived stress to MI: p < 0.001, MI to BRI: p < 0.001). Subsequently, increased BRI was associated with increased total fat intake (p = 0.01). Two-stage mediation was found in the association of prenatal distress with total fat intake. Increased prenatal distress was associated with increased MI (p < 0.001). Higher MI was associated with higher BRI (p < 0.001), and higher BRI was associated with increased total fat intake (p = 0.01). Conclusions: Future intervention studies for overweight or obese pregnant women might focus on stress management to alleviate perceived stress and prenatal distress or on strategies to boost executive functions, each of which might ultimately help to reduce total fat intake.