Impact of trainees involvement on surgical outcomes of abdominal and laparoscopic myomectomy.

BACKGROUND: To determine the association of trainees involvement with surgical outcomes of abdominal and laparoscopic myomectomy including operative time, rate of transfusion, and complications. METHODS: A retrospective cohort study of 1145 patients who underwent an abdominal or laparoscopic myomectomy from 2008-2012 using the American College of Surgeons National Surgical Quality Improvement Program database (Canadian Task Force Classification II-2). RESULTS: Overall, 64% of myomectomies involved trainees. Trainees involvement was associated with a longer operative time for abdominal myomectomies (mean difference 20.17 minutes, 95% Confidence Interval (CI) [11.37,28.97], p < 0.01) overall and when stratified by fibroid burden. For laparoscopic myomectomy, there was no difference in operative time between trainees vs no trainees involvement (mean difference 4.64 minutes, 95% CI [-18.07,27.35], p = 0.67). There was a higher rate of transfusion with trainees involvement for abdominal myomectomies (10% vs 2%, p < 0.01; Odds Ratio (OR) 5.62, 95% CI [2.53,12.51], p < 0.01). Trainees involvement was not found to be associated with rate of transfusion for laparoscopic myomectomy (4% vs 5%, p = 0.86; OR 0.82, 95% CI [0.16,4.14], p = 0.81). For abdominal myomectomy, there was a higher rate of overall complications (15% vs 5%, p < 0.01; OR 2.96, 95% CI [1.77,4.93], p < 0.01) and minor complications (14% vs 4%, p < 0.01; OR 3.71, 95% CI [2.09,6.57], p < 0.01) with no difference in major complications (3% vs 2%, p = 0.23). For laparoscopic myomectomy, there was no difference in overall (6% vs 10% p = 0.41; OR 0.59, 95% CI [0.18,2.01], p = 0.40), major (2% vs 0%, p = 0.38), or minor (5% vs 10%, p = 0.32; OR 0.52, 95% CI [0.15,1.79], p = 0.30) complications. CONCLUSION: Trainees involvement was associated with increased operative time, rate of transfusion, and complications for abdominal myomectomy, however, did not impact surgical outcomes for laparoscopic myomectomy.

TITLE: Trainees Involvement in MyomectomyThe goal of our study was to determine the association of trainees involvement with surgical outcomes of fibroid excision surgery or myomectomy. We conducted a study of abdominal and laparoscopic myomectomies using an international surgical database. We found that trainees involvement in myomectomy was associated with increased operative time, rate of transfusion, and complications for abdominal myomectomy. However, trainees involvement did not impact surgical outcomes for laparoscopic myomectomy.

Prevalence of and Risk Factors for Emergency Department Visits After Outpatient Gynecologic Surgery.

STUDY OBJECTIVE: To identify the prevalence of and risk factors for emergency department (ED) visits within 30 days of outpatient gynecologic surgery. DESIGN: Retrospective cohort study. SETTING: Tertiary academic medical institution. PATIENTS: Adult patients who underwent outpatient surgery (≤1 midnight in the hospital) between January 2018 and September 2019 (N = 2373). INTERVENTIONS: Scheduled outpatient gynecologic surgery for a benign indication. MEASUREMENTS AND MAIN RESULTS: A total of 109 patients (5%) visited the ED within 30 days of surgery. Patients who visited the ED were significantly younger (median age 37 years vs 42 years, p = .02) and had a higher prevalence of abdominal surgical history (67% vs 56%, p = .02) and cardiopulmonary comorbidities (53% vs 40%, p = .007). They were more likely to have undergone a hysterectomy (26% vs 20%) and less likely to have undergone prolapse surgery (4% vs 12%, p = .05). Pain related to the surgical site (42% of ED visits), nausea and/or vomiting (14%), and fever (12%) were the most common surgery-related reasons for ED visits. Medical issues not directly related to surgery accounted for 31% of ED visits. A total of 36% of ED visits resulted in admission. When adjusted for age, insurance status, American Society of Anesthesiologists class, chronic pain and cardiopulmonary comorbidities, abdominal surgical history, primary procedure performed, and surgical route, the following factors were associated with significantly increased risk of visiting the ED: decreasing age (adjusted odds ratio [aOR] 1.2, 95% confidence interval [CI] 1.1-1.3, p <.001), history of abdominal surgery (aOR 1.7, 95% CI 1.1-2.6, p = .017), cardiopulmonary comorbidities (aOR 1.9, 95% CI 1.2-3.0, p = .003), undergoing hysterectomy (aOR 2.0, 95% CI 1.1-3.8, p = .032), and a vulvovaginal surgical route as opposed to abdominal surgical route (aOR 2.4, 95% CI 1.2-5.1, p = .015). CONCLUSION: ED visits after outpatient gynecologic surgery were uncommon, although approximately one-third of visits resulted in admission. Strategies that target our identified risk factors of younger patient age and cardiopulmonary comorbidities may help reduce the ED burden generated by patients undergoing gynecologic surgery.

Preoperative Hematocrit Level and Associated Risk of Transfusion for Myomectomy Based on Myoma Burden and Surgical Route.

STUDY OBJECTIVE: To determine the association between preoperative hematocrit level and risk of blood transfusion for laparotomic and laparoscopic myomectomy based on myoma burden and surgical route. DESIGN: A cohort study of prospectively collected data. SETTING: American College of Surgeons National Surgical Quality Improvement Program participating institutions. PATIENTS: A total of 26 229 women who underwent a laparotomic or laparoscopic myomectomy from 2010 to 2020. INTERVENTIONS: The primary outcome assessed was the risk of transfusion based on preoperative hematocrit level. This was evaluated with respect to myoma burden and surgical route. MEASUREMENTS AND MAIN RESULTS: There were 26 229 women who underwent a myomectomy during the study interval, 2345 women (9%) of whom required a blood transfusion. Compared with patients who did not require transfusion, those who did had lower median preoperative hematocrit levels (34.7 vs 38.2). Patients were stratified by surgical approach (laparotomic vs laparoscopic) and myoma burden (1-4 myomas/weight ≤250 g or ≥5 myomas/weight >250 g) using Current Procedural Terminology codes (58140, 58146, 58545, 58546). In all categories, there was an inverse relationship between blood transfusion and preoperative hematocrit level with increasing risk depending on preoperative hematocrit range. The odds ratios comparing hematocrit level of 29% with 39% were 6.16 (95% confidence interval [CI], 5.15-7.36), 4.92 (95% CI, 4.19-5.78), 4.85 (95% CI, 3.72-6.33), and 5.2 (95% CI, 3.63-7.43) for patients with laparotomic (1-4 myomas/≤250 g, ≥5 myomas/>250 g) and laparoscopic myomectomy (1-4 myomas/≤250 g, 5 myomas/>250 g), respectively. CONCLUSION: Incremental increases in hematocrit result in a significantly decreased risk of blood transfusion at the time of myomectomy.

Abdominal Wall Thickness at Palmer's Point and Distance to Adjacent Structures across the Body Mass Index Spectrum.

STUDY OBJECTIVE: Studies delineating left upper quadrant (LUQ) anatomy across a range of body mass indices are lacking. We aimed primarily to compare, between nonobese and obese women, abdominal wall thickness and the distance from the LUQ to key structures. In addition, we aimed to characterize LUQ anatomy in underweight women. DESIGN: A retrospective cohort study. SETTING: A tertiary academic medical institution. PATIENTS: Sixty women (30 nonobese, 30 obese) aged 18 years and older who underwent abdominal imaging from October 1, 2018, to December 31, 2018. INTERVENTIONS: Computed tomography imaging of the chest, abdomen, and pelvis. MEASUREMENTS AND MAIN RESULTS: Abdominal wall thickness at the LUQ was significantly greater in obese (4.3 ± 1.7 cm) than nonobese patients (2.4 ± 1.7 cm) (p <.001), as were distances to all key structures (aorta, vena cava, spleen, stomach, pancreas, liver, left kidney, and pelvis) (p ≤.02). On average, all structures, with the exception of stomach and liver, were >10 cm (the length of a typical insufflation needle) away from the LUQ insertion point in obese women. In underweight women, the aorta, spleen, stomach, pancreas, and liver were all within 10 cm of the LUQ insertion point. Within the obese and nonobese group, abdominal wall thickness at the LUQ was significantly greater than at the umbilicus (p <.001). Body mass index was more strongly correlated with abdominal wall thickness at the LUQ (r = 0.84; p <.001) than at the umbilicus (r = 0.69; p <.001) (p = .007 for comparison). CONCLUSION: This study highlights special anatomic considerations for LUQ access in obese and underweight patients. In obese women, abdominal wall thickness may be greater at this site than at the umbilicus and the liver and stomach remain within reach of an insufflation needle. The increased working distance from the LUQ to the pelvis in obese patients may necessitate specialized instruments if this site is used during surgery. In underweight women, the aorta, in addition to many other structures, is within reach of commonly used entry devices.

Don't be STUMPed: description and management of uncommon pathologies encountered on specimens from benign gynecologic surgery.

PURPOSE OF REVIEW: In this review, we aim to describe uncommon pathologies that gynecologic surgeons may reasonably encounter on surgical specimens following benign gynecologic surgery. RECENT FINDINGS: Herein, we describe uncommon pathologic findings of the uterus (e.g. squamous morular metaplasia, fibroid variants, stromal tumor of uncertain malignant potential), peritoneum and adnexa (e.g. endosalpingiosis, serous tubal intraepithelial carcinoma), endometriosis (e.g. stromal endometriosis, atypical endometriosis), and findings of particular interest in postmenopausal women (e.g. ovarian cortical stromal hyperplasia, tubal metaplasia). The majority of pathologic findings presented in this article are inherently benign, although they can present diagnostic challenges. If properly classified, additional treatment and/or extended follow-up is often not required; exceptions are highlighted. SUMMARY: The gynecologic surgeon may encounter uncommon pathologies during a career. Inherent diagnostic difficulties, as well as nonstandardized or outdated terminology, can introduce further uncertainty. Whenever such a situation arises, the surgeon and pathologist should discuss the diagnosis to ensure appropriate treatment options.

Ultrasound Visceral Slide Assessment to Evaluate for Intra-abdominal Adhesions in Patients Undergoing Abdominal Surgery - A Systematic Review and Meta-analysis.

OBJECTIVE: Abdominal entry at the time of laparoscopy is a critical step with a risk of injury to underlying viscera owing to bowel adhesions. Ultrasound can be used as a preoperative tool to assess the slide of viscera underneath the abdominal wall to detect adhesion-free areas. The objective of this systematic review and meta-analysis was to determine the diagnostic accuracy of preoperative visceral slide assessment with ultrasound to detect intra-abdominal adhesions, compared with the gold standard of intraoperative findings. DATA SOURCES: Using Cochrane, Medline PubMed, Embase, and Google Scholar electronic databases, 3737 articles were screened in April 2020 using a query that included variations of "adhesions" and "ultrasound." Reference lists of relevant articles were searched for further articles. METHODS OF STUDY SELECTION: Prospective and cross-sectional studies in English that included patients at risk for intra-abdominal adhesions who underwent preoperative ultrasound visceral slide assessment and subsequent intraoperative assessment of adhesions were selected. Two reviewers independently selected 25 articles, extracted data, and assessed bias using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. TABULATION, INTEGRATION, AND RESULTS: Twenty-five articles reported on 1609 patients and 5812 assessed abdominal areas, with considerable heterogeneity of described abdominal areas and degrees of adhesions. Meta-analysis was performed for 21 studies. The periumbilical area was assessed specifically for bowel adhesions in 890 patients in 12 studies, with a 12.0% bowel adhesion rate. Ultrasound assessment for periumbilical bowel adhesions had a combined sensitivity of 95.9% (95% confidence interval, 82.7%-99.1%), specificity of 93.1% (85.1%-96.9%), positive predictive value of 60.4% (44.2%-74.7%), and negative predictive value of 99.2% (97.9%-99.7%) with low heterogeneity (I2 = 16%). CONCLUSION: Visceral slide assessment with ultrasound has a high negative predictive value for the absence of periumbilical bowel adhesions in patients at risk for adhesions and can function as a useful tool to detect adhesion-free areas to allow for safe laparoscopic entry.

Enhanced recovery after surgery in minimally invasive gynecologic surgery surgical patients: one size fits all?

PURPOSE OF REVIEW: Enhanced recovery after surgery (ERAS) programs aim to expedite functional recovery and improve surgical outcomes without increasing complications or cost. First championed by colorectal surgeons, ERAS protocols are now widely utilized among surgical subspecialties. The present review focuses on use of ERAS pathways in minimally invasive gynecologic surgery (MIGS) and risk factors for suboptimal outcomes in this population. RECENT FINDINGS: Studies across multiple fields has shown benefit to adoption of ERAS protocols. However, lack of protocol standardization among institutions, implementation of interventions as a bundle, varied compliance, and lack of study randomization collectively obscure generalizability of findings from such studies. Emerging data in fact suggest benefits may not translate equally across all populations, cautioning against indiscriminate application of protocols to all surgeries or patients. Thus applicability of ERAS protocols to the MIGS population merits close examination. SUMMARY: ERAS protocols improve postoperative outcomes, satisfaction, and cost of care for most patients undergoing gynecologic surgery. However, modifications to typical ERAS protocols may be beneficial to certain subsets of patients including patients with chronic pelvic pain, opiate dependence, or psychiatric disorders. Identification of risk factors for admission or increased hospital stay may help guide protocol modifications for at-risk groups within the MIGS population.

Utilization and cost of cell salvage in minimally invasive myomectomy.

OBJECTIVE: To assess the utilization and cost of intraoperative cell salvage (ICS) in minimally invasive myomectomy. STUDY DESIGN: Retrospective cohort study of patients who underwent minimally invasive myomectomy at a quaternary care academic hospital. Patients were classified into: ICS setup vs no ICS setup, ICS setup with reinfusion vs ICS setup without reinfusion. RESULTS: Of 382 patients who underwent minimally invasive myomectomy, 67 (17.5 %) had ICS setup, 30 (44.8 %) of those patients reinfused. Median volume of reinfusion per patient was 300 mL (range 125-1000 mL). Patients who ultimately underwent ICS reinfusion, compared to those with ICS setup only, had significantly larger mean maximum fibroid size (9.8 cm vs 8.0 cm, p = 0.02), higher median total specimen weight (367 vs 304 g, p = 0.03), higher median estimated blood loss (575 vs 300 mL, p < 0.0001), longer mean operative time (261 vs 215 min, p = 0.04). No perioperative complications were associated with ICS. Higher costs are associated with universal use or complete lack of ICS; lowest cost is associated with ICS setup only for those ultimately reinfused. CONCLUSION: ICS might reduce requirements for allogeneic blood transfusions in patients undergoing minimally invasive myomectomy, and may contribute to cost savings. Uterine and maximum fibroid sizes are possible preoperative indicators for patients who require cell salvage reinfusion.

The prevalence of hyperglycemia and its association with perioperative outcomes in gynecologic surgery: a retrospective cohort study.

BACKGROUND: Preoperative hyperglycemia has been associated with perioperative morbidity in general surgery patients. Additionally, preoperative hyperglycemia may indicate underlying impaired glucose metabolism. Thus, identification of preoperative hyperglycemia may provide an opportunity to mitigate both short-term surgical and long-term health risk. We aimed to study this phenomenon specifically in the gynecologic surgery population. Specifically, we aimed to evaluate the association between preoperative hyperglycemia and perioperative complications in gynecologic surgery patients and to characterize adherence to diabetes screening guidelines. METHODS: This retrospective cohort study included 913 women undergoing major gynecologic surgery on an enhanced recovery pathway from January 2018 to July 2019. The main exposure was day of surgery glucose ≥ 140 g/dL. Multivariate regression identified risk factors for hyperglycemia and composite and wound-specific complications. RESULTS: Sixty-seven (7.3%) patients were hyperglycemic. Diabetes (aOR 24.0, 95% CI 12.3-46.9, P < .001) and malignancy (aOR 2.3, 95% CI 1.2-4.5, P = .01) were associated with hyperglycemia. Hyperglycemia was not associated with increased odds of composite perioperative (aOR 1.3, 95% CI 0.7-2.4, P = 0.49) or wound-specific complications (aOR 1.1, 95% CI 0.7-1.5, P = 0.76). Of nondiabetic patients, 391/779 (50%) met the USPSTF criteria for diabetes screening; 117 (30%) had documented screening in the preceding 3 years. Of the 274 unscreened patients, 94 (34%) had day of surgery glucose levels suggestive of impaired glucose metabolism (glucose ≥ 100 g/dL). CONCLUSION: In our study cohort, the prevalence of hyperglycemia was low and was not associated with higher risk of composite or wound-specific complications. However, adherence to diabetes screening guidelines was poor. Future studies should aim to develop a preoperative blood glucose testing strategy that balances the low utility of universal glucose screening with the benefit of diagnosing impaired glucose metabolism in at-risk individuals.

Post-ablation tubal sterilization syndrome: Does route of sterilization matter?

OBJECTIVE: To compare the prevalence of clinical post-ablation tubal sterilization syndrome among women who underwent abdominal (i.e., peripartum or laparoscopic) vs hysteroscopic permanent contraception in addition to endometrial ablation. STUDY DESIGN: This study was a retrospective cohort study conducted at an academic medical center. We included women (N = 188) who successfully underwent both endometrial ablation and permanent contraception between 2005 and 2017. Forty-one women underwent hysteroscopic permanent contraception and 147 underwent abdominal (i.e., peripartum or laparoscopic) permanent contraception. The primary outcome was the prevalence of clinical post-ablation tubal sterilization syndrome, as defined by new or worsening cyclic pelvic pain after completion of both procedures. RESULTS: The overall prevalence of the syndrome was 19.1% (34 of 178 women who followed up), with no detected difference between those who underwent hysteroscopic (6 of 38, 15.8%) vs abdominal permanent contraception (28 of 140, 20.0%, p = 0.55). In multivariate regression modeling, when adjusted for race, parity, gynecologic pathologies, hormonal medication use, and the presence of baseline pain (both pelvic and non-pelvic) only younger patient age was marginally associated with increased odds of the syndrome (aOR 1.85, 95% CI 1.01- 3.45, p = 0.05), while abdominal as compared to hysteroscopic permanent contraception was not (aOR 1.29, 95% CI 0.59-2.84, p = 0.53). Of the 28 patients with clinical post-ablation tubal sterilization syndrome who underwent hysterectomy and/or salpingectomy as treatment for their pain, none showed signs of hematosalpinx or hematometra at the time of surgery or on final pathology. CONCLUSION: We did not find evidence that route of permanent contraception affects the risk of post-ablation tubal sterilization syndrome development. Younger patients may be at higher risk of this syndrome.

Prevalence of Dental Caries Among Costa Rican Male Students Aged 12-22 Years Using ICDAS-II / Prevalencia de caries en varones costarricenses escolarizados de 12 a 22 años utilizando ICDAS-II

ABSTRACT: Objective: Dental decay is a public health challenge in Low- and Middle- Income Countries, particularly for young people, often confronted to healthcare access barriers. The aim of this study was to determine the prevalence and severity of dental caries among young male students in Costa Rica. Study design: A cross-sectional study was performed in 428 Costa Rican male students aged 12-22 years, who attended a nonprofit social welfare boarding school in 2019. A clinical examination was ran by three calibrated examiners following the International Caries Detection and Assessment System (ICDAS-II). Results: Caries prevalence was estimated at 83%, 15% have lost a tooth due to dental decay, 61% have at least one filled tooth, 36% have at least one filled and decayed tooth. The most frequent caries lesions were codes 2-Inactive (46.7%) and code 1-Inactive (23.8%). DMFT indicated a mean index using ICDAS-II 1-6>0 codes of 7.89. Using ICDAS-II 3-6>0 as threshold, the index decreases to 3.94. Finally, the lower and upper first permanent molars were found to be the most affected teeth. Conclusions: Dental caries experience represents a significant public health burden in young people, requiring better access to public dental healthcare.

RESUMEN: Objetivo: La caries dental continúa siendo uno de los grandes desafíos de salud pública en los países de ingresos bajos y medios, en particular para los jóvenes, que a menudo se enfrentan a barreras de acceso a la atención médica y odontológica. El objetivo de este estudio es determinar la prevalencia y severidad de la caries dental entre jóvenes estudiantes varones en Costa Rica. Diseño del estudio: se realizó un estudio transversal con 428 estudiantes varones costarricenses de entre 12 y 22 años, que asistieron a un internado de asistencia social sin fines de lucro llamado Ciudad de los Niños en 2019. Tres examinadores calibrados realizaron un examen clínico siguiendo el Sistema Internacional de Detección y Evaluación de Caries. (ICDAS-II). Resultados: La prevalencia de caries se estimó en 83%, el 15% ha perdido un diente debido a caries dental, el 61% tiene al menos un diente obturado, el 36% tiene al menos un diente obturado y con caries. Las lesiones de caries más frecuentes fueron los códigos 2-Inactivo (46,7%) y el código 1-Inactivo (23,8%). CPOD indicó un índice medio utilizando códigos ICDAS-II 1-6>0 de 7,89. Usando ICDAS-II 3-6>0 como umbral, el índice disminuye a 3,94. Finalmente, los primeros molares permanentes inferiores y superiores resultaron ser los dientes más afectados. Conclusiones: La experiencia de la caries dental representa una carga de salud pública significativa en los jóvenes, que requiere un mejor acceso a la atención médica dental pública.