Opioid Use After Laparoscopic Surgery for Endometriosis and Pelvic Pain.

STUDY OBJECTIVE: The primary objective was to quantify postoperative opioid use after laparoscopic surgery for endometriosis or pelvic pain. The secondary objective was to identify patient characteristics associated with greater postoperative opioid requirements. DESIGN: Prospective, survey-based study in which subjects completed 1 preoperative and 7 postoperative surveys within 28 days of surgery regarding medication usage and pain control. SETTING: Tertiary care, academic center. PATIENTS: A total of 100 women with endometriosis or pelvic pain. INTERVENTIONS: Laparoscopic same-day discharge surgery by fellowship-trained minimally invasive gynecologists. MEASUREMENTS AND MAIN RESULTS: A total of 100 patients were recruited and 8 excluded, for a final sample size of 92 patients. All patients completed the preoperative survey. Postoperative response rates ranged from 70.7% to 80%. The mean number of pills (5 mg oxycodone tablets) taken by day 28 was 6.8. The average number of pills prescribed was 10.2, with a minimum of 4 (n = 1) and maximum of 20 (n = 3). Previous laparoscopy for pelvic pain was associated with a significant increase in postoperative narcotic use (8.2 vs 5.6; p = .044). Hysterectomy was the only surgical procedure associated with a significant increase in postoperative narcotic use (9.7 vs 5.4; p = .013). There were no difference in number of pills taken by presence of deep endometriosis or pathology-confirmed endometriosis (all p >.36). There was a trend of greater opioid use in patients with diagnoses of self-reported chronic pelvic pain, anxiety, and depression (7.9 vs 5.7, p = .051; 7.7 vs 5.2, p = .155; 8.1 vs 5.6, p = .118). CONCLUSION: Most patients undergoing laparoscopic surgery for endometriosis and pelvic pain had a lower postoperative opioid requirement than prescribed, suggesting surgeons can prescribe fewer postoperative narcotics in this population. Patients with a previous surgery for pelvic pain, self-reported chronic pelvic pain syndrome, anxiety, and depression may represent a subset of patients with increased postoperative opioid requirements.

Laparoscopic Major Vascular Injuries in Gynecologic Surgery for Benign Indications: A Systematic Review.

OBJECTIVE: To identify the incidence, location, etiology, and mortality of major vascular injuries in gynecologic laparoscopy for benign indications. DATA SOURCES: A systematic review of PubMed, EMBASE, Cochrane Library, ClinicalTrials.gov, and MEDLINE was conducted. METHODS OF STUDY SELECTION: One thousand ninety-seven studies were screened for inclusion with 147 full-text articles reviewed. Sixty-six studies published between 1978 and 2016 met inclusion criteria, representing 197,062 surgeries. Articles that were included reported the incidence of major vascular injuries during gynecologic laparoscopy for benign indications. Exclusion criteria included surgery for gynecologic malignancy, duplicated data, case series and reports, manuscripts not in English, and studies published only as abstracts. TABULATION, INTEGRATION, AND RESULTS: Injuries to the aorta, inferior vena cava, iliac (common, external, or internal), and inferior epigastric vessels were recorded, as were injuries denoted as major but not otherwise specified. A total of 179 major vascular injuries were reported with an incidence of 0.09% (95% CI 0.08-0.10). The inferior epigastric vessels were the most commonly injured vessel (0.04%, 95% CI 0.03-0.05), comprising 48% (95% CI 40-55) of all injuries. The majority of injuries occurred during abdominal entry (82%, 95% CI 76-89), and the remainder occurred during surgical dissection (18%, 95% CI 11-24). Most injuries were recognized intraoperatively (93%, 95% CI 87-100), and approximately half (55%, 95% CI 46-63) required laparotomy for repair. Only two of the 179 major vascular injuries resulted in death, for an overall mortality rate from vascular injuries of 0.001% (95% CI 0.000-0.004). CONCLUSION: The incidence of major vascular injury during gynecologic laparoscopy found in this review is very low, and the vast majority of injuries did not result in death. Laparoscopy remains a safe surgical technique in relation to vascular injuries when performed for benign gynecologic disease.

The burden of diabetes-related foot disorders in community-dwellers living in rural Ecuador: Results of the Atahualpa Project.

BACKGROUND/OBJECTIVES: Prevalence of diabetes-related foot disorders (DRFD) in rural areas of developing countries is unknown. The burden of these conditions in Atahualpa, a rural Ecuadorian village, were assessed. METHODS: Using a population-based design, Atahualpa residents aged ≥40 years with diabetes mellitus were identified. Ankle brachial index determinations were used to assess presence of peripheral arterial disease, and the Michigan Neuropathy Screening Instrument was used to estimate peripheral neuropathy. Ulcers in the foot/ankle as well as history of amputations were considered as evidence of active diabetic foot disease. Using a linear model of risk, factors that independently correlated with DRFD, were assessed. RESULTS: Mean age of 110 participants was 64±12years (59% women). Peripheral arterial disease was diagnosed in 24% of cases and peripheral neuropathy in 59% (15% had both conditions). In the adjusted model, increasing age and being men increased the risk for DRFD. Active diabetic foot disease was noted in 7% of participants, and another 60% were at moderate-to-high risk for developing this complication (according to NHS Borders Foot Classification System). CONCLUSIONS: The prevalence of DRFD is high in rural Ecuador, and most of the affected individuals are at risk for developing active diabetic foot disease.

Calcifications in the carotid siphon inversely associate with cognitive performance in stroke-free community dwellers living in rural Ecuador (The Atahualpa Project).

We aimed to assess whether carotid siphon calcifications (as seen on computed tomography) are associated with worse performance in the Montreal Cognitive Assessment in 584 stroke-free individuals living in rural Ecuador. Using mean Montreal Cognitive Assessment score of subjects with Grade 1 calcifications (23.1 ± 4.2) as the referent category, fully adjusted generalized linear models showed significant associations between severity of carotid siphon calcifications and cognitive performance (mean Montreal Cognitive Assessment scores: 20.2 ± 4.8 for Grade 2 (p = 0.004), 19.7 ± 5.3 for Grade 3 (p = 0.0001), and 18.8 ± 4.1 for Grade 4 (p = 0.02)). Predictive Montreal Cognitive Assessment score margins were higher in individuals with Grade 1 calcifications than in other groups. This study shows an inverse relationship between calcium content in the carotid siphon and cognitive performance in Amerindians.

Population-based study of alcoholic cerebellar degeneration: The Atahualpa Project.

BACKGROUND: There are no population studies estimating the burden of alcoholic cerebellar degeneration (ACD). We aimed to assess prevalence and correlates of ACD among chronic alcohol drinkers living in rural Ecuador. METHODS: Characteristics of alcohol intake were evaluated in community-dwelling men aged ≥40years enrolled in the Atahualpa Project. Cerebellar dysfunction evaluation used the Brief Ataxia Rating Scale (BARS). Association between alcohol intake and the BARS was assessed in generalized linear models adjusted for relevant confounders. In subjects who had CT, the relationship between cerebellar atrophy and the BARS was evaluated. RESULTS: Of the 313 men identified during a door-to-door survey, 246 (79%) were enrolled. All admitted continuous drinking for ≥10years. Of these, 41% started drinking below legal age (18years), 72% were current drinkers, and 83% engaged in binge drinking. Average alcohol intake was 330±351g/week. Mean BARS score was 1.4±2 points, with 14.6% (95% C.I.: 10.8%-19.6%) of individuals having ≥4 points and considered to have clinically relevant ACD. The BARS was associated with years of drinking (p=0.036), amount of alcohol intake (p<0.0001), and binge drinking (p=0.026). Predictive models showed significant relationships between BARS score margins and years of drinking and the amount of alcohol intake, independent of other variables. There was no association between cerebellar atrophy on CT and the BARS in 214 participants. CONCLUSIONS: Prevalence of clinically relevant ACD in this population is low. There are both independent and synergistic effects of years of drinking, amount of alcohol intake and binge drinking in the severity of cerebellar dysfunction.