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Objectives: To determine the rate and identify factors associated with potentially avoidable admissions following a minimally invasive hysterectomy. Methods: Patients who underwent a minimally invasive hysterectomy for a suspected or known gynecologic malignancy between January 2019 to July 2021 were identified in our institution's prospectively curated quality improvement surgical database. Preoperatively, patients were assessed for planned same-day discharge versus a planned admission. Reasons for those who were admitted despite a planned same-day discharge were characterized as the following: anesthesia-related, comorbid conditions, intraoperative factors, social factors, system issues, and uncontrolled pain. For planned admissions, reasons for admission were categorized as necessary and potentially unavoidable. Descriptive statistics were used to summarize the cohort. Results: A total of 380 patients were identified, of which 267 (70%) patients had a planned same-day discharge, and 113 (30%) had an anticipated admission. Same-day surgery discharge rates increased over time (Figure 1). Two hundred and thirty-five patients (88%) were successfully discharged the same day. Of these patients, 17 (7%) presented to the emergency department (ED) within 30 days, and the re-admission rate in this group was 12% (n=2). Thirty-two patients did not successfully discharge on the same day, and five patients (15%) presented to the ED for evaluation within 30 days. Most unplanned admissions were anesthesia-related (n=15, 47%), followed by system issues (n=7, 22%), such as failure to recognize comorbid conditions in the preoperative period, intraoperative factors (n=5, 16%), postoperative pain (n=3, 9%), and social factors (n=2, 6%). Among the 113 anticipated admissions, 78 (69%) patients were deemed necessary due to multi-factorial comorbid conditions or surgical complexity. However, 35 (31%) patients could have been optimized for same-day discharge;reasons for which included patients with comorbid conditions that could have been optimized preopera- tively, such as poorly controlled diabetes (n=13, 12%), system issues, (n= 8, 7%), social factors (n= 7, 6%), anesthesia-related (n= 4, 4%), and surgical complexity (n=3, 3%). [Formula presented] Conclusions: Most patients were successfully discharged the same day, and of those who were deemed unsuitable for same-day discharge, nearly half could have been optimized for same-day discharge. Unplanned admissions in the anticipated same-day discharge cohort were primarily due to anesthesia-related concerns in the immediate postoperative period and where patient comorbid conditions could have been better optimized in the preoperative period. Recognizing potential areas for improvement and further optimizing same-day discharge will allow hospital systems to continue providing care for gynecologic oncology patients during COVID-19 surges.
RESUMO
Objectives: To evaluate the surgical volume, surgical outcomes, and the evolving role of gynecologic oncologists in peripartum hysterectomies (PPH). Methods: We conducted an IRB-approved retrospective chart review of PPH cases performed at our institution from June 1, 2014, to June 30, 2021. Clinical-pathologic information was ed into a REDCap database. All analyses were conducted using STATA 17. Results: A total of 109 cases were performed over the 7-year period. Gynecologic oncologists (GYO) involvement in the cases increased from 33% in 2014 to 80% in 2021. The mean age was 36 (range: 23-47) years. Most patients were White (81/109, 74.3%), and the median BMI was 30.7 (range: 21-57) kg/m2. Surgical indications included placenta accreta syndrome (PAS) in 84 (77%) cases, uterine atony in ten (9.2%), uterine rupture in three (2.8%), malignancy in five (4.6%), and hemorrhage other than atony in seven cases (6.4%). Intraoperative complications included bladder injury (or intentional dissection) in eight (7.3%), ureter injury in four (3.7%), vascular injury in three (2.8%), and femoral pseudoaneurysm in one (0.9%) of the cases. Postoperative complications included urinary tract infection in 11 (10.1%), nerve injury in one (0.9%), surgical site infection in 13 (11.2%), and venous thromboembolism in five (4.6%) cases. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) usage started in 2019 with one case followed by six cases in 2020 (31.6%) and 3/16 cases in the first half of 2020 (15.8%). A higher REBOA usage in 2020 corresponded with blood products shortages during the COVID crisis.[Formula presented] Conclusions: Overall volume and complexity of peripartum hysterectomy are increasing. This trend is likely driven by an increased incidence of placenta accreta syndrome cases. Gynecologic oncologists are increasingly delegated as primary surgeons in many institutions. Fellowship training programs should strongly consider training in peripartum hysterectomy for trainees.
RESUMO
Objectives: To investigate the utility of symptom review, serum CA125, and physical exam in the detection of ovarian cancer recurrence to determine the role of virtual surveillance care in the post- COVID-19 era. Methods: Patients diagnosed with ovarian cancer between 2013 and 2020 were identified and included if they completed standard of care treatment with surgical resection and platinum doublet chemotherapy, had no evidence of disease after completion of treatment, and had recurrence of disease detected by symptoms, CA125, physical exam, or imaging. Patients were excluded if they did not have pretreatment elevated serum CA125 (>35 U/ml) or a complete medical record. All recurrences were confirmed with imaging or biopsy. Modalities of recurrence detection were defined as the following: symptoms, physical exam, elevated CA125, or other. “Other” was denoted if imaging studies were obtained for reasons other than suspected recurrence and recurrence was incidentally identified. Descriptive statistics were used to summarize the cohort. Kaplan Meier analyses were used to estimate overall survival. Results: 109 patients met criteria at our institution. At initial diagnosis, the median age was 61 years (range 33-84) and most patients had advanced-stage disease, with 73 (67%) patients with Stage III disease and 26 (23.9%) with Stage IV disease. The median time to recurrence was 12 months (range 3-65) and median overall survival was 56 months (95% CI 46-79). In 46 (42.2%) patients, recurrence was suspected based on multiple modalities. At time of recurrence, elevated CA125 was present in 97 (89.0%) patients, symptoms in 41 (37.6%) patients, and abnormal physical exam findings in 27 (24.8%) patients. Of patients with abnormal physical exam, 26 (96.3%) also had elevated CA125 or symptoms present. Recurrence was suspected based on abnormal physical exam findings alone in 1 (0.9%) patient. Detection modalities other than abnormal physical exam (e.g., CA125, symptoms) were present in 102 (93.6%) patients. Recurrence was incidentally found with imaging obtained for reasons other than suspicion of recurrence in 6 (5.5%) patients.(Table Presented) Conclusions: Most ovarian cancer recurrences can be detected by rising CA125 or symptoms. Physical exam may have limited value in the detection of recurrence. Review of CA125 and symptoms can be conducted virtually. The inclusion of virtual visits for ovarian cancer surveillance should be considered for patients with pretreatment elevated CA125.