Avoidable admissions after minimally invasive hysterectomy.

OBJECTIVE: To determine the rate of avoidable admissions following anticipated same-day discharge for patients undergoing minimally invasive hysterectomy and to identify risk factors associated with such admissions. METHODS: A retrospective review was performed of patients who underwent a minimally invasive hysterectomy between March 2019 and July 2021 for a suspected gynecologic malignancy at a single tertiary care center. Pre-operatively, patients were assessed for same-day discharge versus planned admission. Reasons for day-of-surgery admission despite anticipated same-day discharge were categorized as anesthesia-related, system issues, intra-operative factors, post-operative pain, and social factors. Patients deemed not candidates for same-day discharge were defined as planned admissions. Indications were categorized as necessary or potentially avoidable. Descriptive and comparative statistics were used to summarize the cohort. RESULTS: In total, 372 patients were identified: 261 (70.2%) anticipated same-day discharges and 111 (29.8%) planned admissions. Of anticipated same-day discharges, 230/261 (88.1%) were successfully discharged, while 31/261 (11.9%) required admission. Reasons for unplanned admissions were anesthesia-related (14/31, 45.2%), system issues (7/31, 22.6%), intra-operative factors (5/31, 16.1%), post-operative pain (3/31, 9.7%), and social factors (2/31, 6.5%). Among the 111 pre-operatively planned admissions, 81 (73.0%) were necessary due to comorbidities or surgical complexity, while 30 (27.0%) were potentially avoidable because patients could have been optimized for same-day discharge. Opportunities for optimization pre-operatively included comorbidities (13/30, 43.3%), system issues (8/30, 26.7%), social factors (6/30, 20.0%), and provider preference (3/30, 10.0%). CONCLUSION: Most patients undergoing minimally invasive hysterectomy can be safely discharged the same day. Potentially avoidable admissions were primarily related to patient comorbidities that can be better optimized pre-operatively.

Small bite fascial closure technique reduces incisional hernia rates in gynecologic oncology patients.

BACKGROUND: The potential for the technique of small bite fascial closure in mitigating incisional hernias in gynecologic oncology patients still needs to be investigated. OBJECTIVE: To evaluate the impact of closure of small fascial bites compared with prior standard closure on incisional hernia rates in gynecologic oncology patients. METHODS: This is a retrospective cohort study comparing patient outcomes before and after the intervention at a single institution at a comprehensive cancer center. Patients who underwent laparotomy with a vertical midline incision for a suspected or known gynecologic malignancy with a 1-year follow-up were included. The pre-intervention cohort (large bites) had 'mass' or modified running Smead-Jones closure. In contrast, the post-intervention cohort had fascial bites taken 5-8 mm laterally with no more than 5 mm travel (small bites) closure using a 2-0 polydioxanone suture.The primary outcome was the incisional hernias rate determined by imaging or clinical examination within the first year of follow-up. Patient factors and peri-operative variates of interest were investigated for their association with hernia formation through univariate and multivariate analyses. These included age, body mass index (BMI), smoking history, estimated blood loss, pre-operative albumin, American Society of Anesthesia (ASA) physical status classification, or treatment with chemotherapy post-operatively. RESULTS: Of the 255 patients included, the total hernia rate was 12.5% (32/255 patients). Patient characteristics were similar in both cohorts. Small bite closure led to a significant reduction in hernia rates from 17.2% (22/128 patients) to 7.9% (10/127 patients), p=0.025. According to logistic regression modeling, small bite closure (OR=0.40, 95% CI 0.17 to 0.94, p=0.036) was independently associated with lower odds of hernia formation. Other factors associated with increased hernia rates were chemotherapy (OR=3.22, 95% CI 1.22 to 8.51, p=0.019) and obesity (OR=23.4, 95% CI 3.09 to 177, p=0.002). In obese patients, small bite closures led to maximal hernia rate reduction compared with large bites. CONCLUSIONS: The small bite closure technique effectively reduces hernia rates in gynecologic oncology patients undergoing midline laparotomy.

Provider compliance with a tailored opioid prescribing calculator in gynecologic surgery.

OBJECTIVE: To evaluate the impact a tailored opioid prescription calculator has on meeting individual patient opioid needs while avoiding opioid over prescriptions. METHODS: Our group previously developed and published an opioid prescribing calculator incorporating patient risk factors (history of depression, anxiety, chronic opioid use, substance abuse disorder, and/or chronic pain) and type of surgery (laparotomy or laparoscopy). This calculator was implemented on 1/1/2021 and its impact on opioid prescriptions was evaluated until 12/31/21. The primary outcome of the present study is to determine prescriber compliance with the calculator (defined as not overprescribing from the number of pills indicated by the calculator). The secondary outcome is to determine the excess prescription rate (defined as proportion of patients reporting more than 3 pills remaining at 30 days post-surgery). Refill rates and pain related patient phone calls were collected. Descriptive statistics were used to summarize the cohort. RESULTS: Of the 355 patients included, 54.7% (N = 194) underwent laparoscopy and 45.4% (N = 161) underwent laparotomy. One hundred and forty-two patients (40%) had at least one risk factor for opioid usage. The median number of opioid pills prescribed following laparoscopy was 3 (range 0-15) and 6 (0-20) after laparotomy. The prescriber compliance was 88.2% and the excess prescription rate was 25.1% (N = 89 patients). CONCLUSIONS: Our tailored opioid calculator has a high prescriber compliance. Implementation of this calculator led to a standardization of tailored opioid prescribing, while limiting the number of over prescriptions. A free web version of the calculator can be easily accessed at www.opioidcalculator.org.

Optimization of postoperative opioid prescriptions in gynecologic oncology: Striking a balance between opioid reduction and pain control.

OBJECTIVE: To implement a quality-improvement initiative to assess the impact various patient and procedural factors have on postoperative opioid use. To develop a tailored opioid prescribing algorithm for gynecologic oncology patients. METHODS: A retrospective cohort study was performed of patients who underwent a laparoscopy or laparotomy procedure for a suspected or known gynecologic malignancy between 3/2019-9/2020. Patients were assessed preoperatively for the presence of suspected risk factors for opioid misuse (depression, anxiety, chronic pain, current opioid use, or substance abuse). Patients completed a 30-day postoperative questionnaire assessing for total opioid pill use and refills requests. Multivariate models were developed to estimate the independent effect of sociodemographic characteristics, risk factors for opioid misuse and procedural factors on patient reported postoperative opioid use. RESULTS: A total of 390 patients were analyzed. Thirty-nine percent (N = 151/390) of patients reported not using opioids after discharge and 5% (N = 20/390) received an opioid refill. For both minimally invasive procedures and laparotomy procedures, body mass index, comorbidities, intraoperative or postoperative complications and final diagnosis of malignancy were not associated with the amount of opioid consumption. However, younger age and history of risk factors for opioid misuse significantly impacted postoperative opioid use. In multivariate analysis, age (p = 0.038) and risk factors (p < 0.001) remained significant after controlling for other factors. CONCLUSIONS: Two out of every five patients did not use opioids after surgery. Younger patients and those with risk factors for opioid misuse need a tailored approach to prescribing opioids to balance the need for adequate pain control with the risk of misuse.

Patient reported opioid usage following vulvar surgery in gynecologic oncology.

Background: There remains a paucity of data for vulvar surgery outcomes in gynecologic oncology in the era of Enhanced Recovery After Surgery (ERAS) ®. As such, the primary objective is to assess the impact of patient and procedural factors on patient reported postoperative opioid usage following vulvar surgery. Secondary objective is to create a tailored opioid prescribing algorithm for this population. Methods: A retrospective cohort study was performed of patients who underwent vulvar surgery for a gynecologic malignancy between 3/2019-7/2022. Covariates of interest included a history of risk factors for opioid usage, age, anatomic location of the vulvar resection, radicality of surgery, groin dissection, use of postoperative non-steroidal anti-inflammatory drugs (NSAIDs), and complications. Logistic regression models evaluated the effects that sociodemographic characteristics and procedural factors have on opioid usage. Linear regression models were created to determine prescribing guidelines. Results: A total of 100 patients were included. Following surgery, 35 patients (35 %) were not sent home with an opioid prescription, 39 patients (39 %) reported using at least one opioid pill from their prescription, and 26 patients (26 %) reported not using any opioid pills from their prescription. In the regression models, patient age (p < 0.006) had a significant impact on opioid use, while all other factors did not. Contraindications to NSAIDs did not have a statistically significant impact (p = 0.1) but was deemed clinically meaningful and included in the final model. Proposed opioid prescribing guidelines were created. Conclusion: In conclusion, most patients after vulvar surgery require little to no opioids. Identifiable preoperative factors can aid providers to manage postoperative pain while minimizing unnecessary opioid prescriptions.

Differences in sacral neuromodulation device infection rates based on preoperative antibiotic selection.

INTRODUCTION AND HYPOTHESIS: After SNM implantation the most significant complication that can occur is wound infection, which typically requires removal of all components. Such infections have been reported in 5-11 % of patients, but little is known about risk factors. The objective of this analysis is to determine our postoperative wound infection rate after SNM implantation, and examined various potential predictive factors. Our hypothesis is that perioperative antibiotic selection is related to the risk of infections. METHODS: A retrospective review was performed of all patients who underwent SNM implantation by one of three surgeons from 2007 to 2010. Preoperative antibiotics were administered according to surgeon preference, and included cefazolin alone, vancomycin alone, or vancomycin with gentamicin. Predictors of wound infection were evaluated using multivariate techniques. Variables examined included preoperative antibiotic regimen, surgeon, location (outpatient surgery center vs university hospital), gender, comorbidities (diabetes mellitus, immunosuppression and smoking), history of urinary tract infections, and preoperative skin preparation. RESULTS: A total of 136 patients underwent SNM implantation, and 8 (5.9 %) experienced infections that required device explantation. Cefazolin alone was less effective in preventing infection compared with the other antibiotic regimens (p = 0.03). The odds of having an infection in cefazolin-treated patients was 7.3 times that of other patients treated with another antibiotic regimen. Seven out of the eight infections with explant grew Staphylococcus aureus resistant to cephalosporins. None of the other variables proved to be a statistically significant contributor. CONCLUSIONS: Preoperative antibiotic selection was a significant factor in preventing subsequent infection and explantation following SNM placement.

Lack of osteoradionecrosis of the mandible after intensity-modulated radiotherapy for head and neck cancer: likely contributions of both dental care and improved dose distributions.

PURPOSE: To assess the prevalence and dosimetric and clinical predictors of mandibular osteoradionecrosis (ORN) in patients with head and neck cancer who underwent a pretherapy dental evaluation and prophylactic treatment according to a uniform policy and were treated with intensity-modulated radiotherapy (IMRT). METHODS AND MATERIALS: Between 1996 and 2005, all patients with head-and-neck cancer treated with parotid gland-sparing IMRT in prospective studies underwent a dental examination and prophylactic treatment according to a uniform policy that included extractions of high-risk, periodontally involved, and nonrestorable teeth in parts of the mandible expected to receive high radiation doses, fluoride supplements, and the placement of guards aiming to reduce electron backscatter off metal teeth restorations. The IMRT plans included dose constraints for the maximal mandibular doses and reduced mean parotid gland and noninvolved oral cavity doses. A retrospective analysis of Grade 2 or worse (clinical) ORN was performed. RESULTS: A total of 176 patients had a minimal follow-up of 6 months. Of these, 31 (17%) had undergone teeth extractions before RT and 13 (7%) after RT. Of the 176 patients, 75% and 50% had received >or=65 Gy and >or=70 Gy to >or=1% of the mandibular volume, respectively. Falloff across the mandible characterized the dose distributions: the average gradient (in the axial plane containing the maximal mandibular dose) was 11 Gy (range, 1-27 Gy; median, 8 Gy). At a median follow-up of 34 months, no cases of ORN had developed (95% confidence interval, 0-2%). CONCLUSION: The use of a strict prophylactic dental care policy and IMRT resulted in no case of clinical ORN. In addition to the dosimetric advantages offered by IMRT, meticulous dental prophylactic care is likely an essential factor in reducing ORN risk.