Gynecologic Surgical Patients Research Articles

Financial toxicity among gynecologic oncology surgical patients

Financial toxicity among gynecologic oncology surgical patients

Reduced symptom burden after implementation of an electronic symptom management program.

12006 Background: The SIMPRO consortium implemented an electronic patient reported outcomes (ePRO) symptom management program as part of routine clinical care for patients (pts) receiving systemic cancer therapy or surgery across six health systems including rural and community cancer centers. To evaluate impact of the Epic-integrated electronic symptom management (eSyM) program on quality of life, pre- and post-implementation surveys were sent to a subset of gastrointestinal, thoracic, and gynecologic medical oncology (MO) and surgical (Surg) patients at all sites. Methods: A survey assessing symptom burden, health literacy, and self-efficacy was administered to separate groups of MO and Surg pts before (Pre-Implementation) and after (Post-Implementation) eSyM deployment. A waiver of documentation of consent was obtained for participation. Questions were derived from validated instruments including PROMIS, a standardized measurement tool for patient-reported symptoms. Surveys were completed 30-90 days after surgery or start of systemic therapy. PROMIS item responses were scored individually then translated into standardized T-scores with a mean of 50 based on an established reference population. Mean T-scores for PROMIS depression, anxiety, fatigue, and pain interference were calculated. Higher T-score correlated with greater symptom burden. Comparison between groups utilized non-parametric Kruskal-Wallis testing. Results: The number of survey responses were 498 MO Pre-Implementation, 518 MO Post-Implementation, 566 Surg Pre-Implementation, and 507 Surg Post-Implementation. MO pts reported significantly lower PROMIS mean T-scores for depression, anxiety, fatigue, and pain interference after eSyM compared to a similar group of MO pts prior to eSyM. Surg pts reported lower T-scores for depression, anxiety, fatigue, and pain interference after eSyM compared to a similar group of Surg pts prior to eSyM, although reduction in pain interference was not statistically significant. Conclusions: eSyM deployment in MO was associated with a significant reduction in patient reported depression, anxiety, fatigue, and pain interference. Surgical pts after eSyM deployment reported significantly lower rates of depression, anxiety, and fatigue. External validation with PROMIS based surveys demonstrated small but meaningful benefits of ePRO symptom monitoring as part of routine clinical care across six diverse health systems. Clinical trial information: NCT03850912 . [Table: see text]

The prevalence and factors associated with acute postoperative pain in elective gynecologic surgical patients at two referral hospitals in Addis Abeba, Ethiopia, 2021: a cross-sectional study.

This study aimed to determine the prevalence and factors associated with acute postoperative pain. A cross-sectional study was conducted at Minilik and Zewditu Referral hospitals from October to December 2021 and chart review and face-to-face interviews were the methods of data collection. The pain was measured at the 2, 12, and 24h postoperatively through a numerical rating scale, and the pain was categorized as no pain (score=0), mild pain (score 1-3), moderate pain (score 4-6), or severe pain (score 7-10). All independent variables with P less than or equal to 0.2 in the univariable logistic regression were reanalyzed with multivariable logistic regression at 95% CI to determine predictive factors and a P-value of less than 0.05 was considered statistically significant. In the study period, a total of 368 eligible patients were involved, out of this 11 patients were discharged before 24h, four patients refuse to participate two incomplete documentation and one patient was ICU admitted, therefore 350 patients were involved with a response rate of 95.1%. Among those patients 73.1% of respondents' experience at least one episodes of moderate to severe postoperative pain within the first 24h. Preoperative anxiety (AOR: 2.2, 95% CI: 1.2, 5.1), urban residency (AOR: 2.3, 95% CI: 1.2, 50), participants who have not formal education (AOR: 2.5, 95% CI: 1.3, 4.1), surgical patients without pre-emptive analgesia (AOR: 2.7, 95% CI: 1.3, 3.6), abdominal incision greater than 10cm (AOR: 3.5, 95% CI: 2.1, 7.2), and surgical duration greater than or equal to 60min (AOR: 2.3, 95% CI: 1.1, 3.1) were factors associated with acute postoperative pain following elective gynecologic surgery. In this study, the overall incidence of moderate to severe postoperative pain after gynecologic surgery was unacceptably high, and patients undergoing gynecologic surgical procedures suffer sufficient postoperative pain need of intervention.

Outcomes of Gynecologic Cancer Surgery During the COVID-19 Pandemic: An International, Multicenter, Prospective CovidSurg–Gynecologic Oncology Cancer Study

ABSTRACT The logistic strain on the health care system during the COVID-19 pandemic disproportionally affected women with gynecologic cancers and surgical care delivery. Surgeries were being delayed or replaced by systemic or palliative care options with less favorable outcomes. The true impact of pandemic-related modifications to clinical management of surgical gynecologic cancer patients remains unknown. This international prospective cohort study aimed to analyze the clinical and surgical outcomes of patients with gynecologic cancer who had or were planned to have first-line treatment during the COVID-19 pandemic. This study was part of an umbrella study exploring the impact of COVID-19 in surgical patients across all solid cancer types and multiple specialties (GlobalSurg-CovidSurg Consortium). All hospitals that included patients discussed for surgery regardless of whether they were operated on or not were included in this study. Patients who were planned for curative or life-prolonging surgery or underwent surgery for gynecologic cancer during the COVID-19 pandemic were included. Patients were followed up from the time of multidisciplinary team decision for surgery for the next 3 months, representing the first peak period of the pandemic. The primary outcome was the incidence in pandemic-related changes in care, whereas secondary outcomes included perioperative morbidity and mortality, wait time before surgery, postoperative hospital stay time, proportion of patients not operated on with progression to incurable disease or death, and a composite adverse outcome to measure the potential impact of any treatment delays or adjustment. A total of 3973 patients from 227 centers across 52 countries were included, of whom 3784 (95.2%) ultimately underwent surgery. The majority of patients had uterine or ovarian cancer (n = 3270 [82%]) and were from high-income countries (n = 2906 [73%]). A total of 189 operations (7.9%) were canceled. Although the median time from multidisciplinary team decision to surgery was 3 weeks, 11.2% (424/3784) of patients underwent surgery more than 8 weeks later. Among ovarian cancer patients with stage III/IV disease and a significant delay (>8 weeks) of surgery, 83.6% had neoadjuvant chemotherapy compared with 21% for those who did not experience a delay (P < 0.0001). The overall 30-day postoperative complication rate was 19.3%, and the postoperative COVID-19 infection rate was 0.6%. The length of stay was significantly longer for COVID-19–infected patients (median, 8.5 vs 4 days; P = 0.0001). When evaluating the entire cohort, a total of 20.7% (823/3973) had their standard of care adjusted because of the pandemic. Patients in low- and middle-income countries (P < 0.0001), areas under full lockdown (P < 0.0001), with worse performance status (P < 0.0001), more comorbidities (P = 0.0242), higher American Society of Anesthesiologists grade (P = 0.010), ovarian cancer (P < 0.001), and stage 3 or 4 diseases (P < 0.0001) were more likely to have their operations more than 8 weeks after the MTD decision. There was no significant difference in 30-day mortality among those with delayed operations; however, a significant difference was observed for the adverse composite outcome owing to delay including unresectable disease or disease progression, emergency surgery, and death (95/424 [22.4%] vs 601/3360 [17.9%]; P = 0.024). The results of this study demonstrate that despite a very low risk of perioperative COVID-19 infection, a significant portion of gynecologic cancer surgical patients had treatment plan modifications associated with early negative impact.

Obtaining Consent for Educational Pelvic Exams Under Anesthesia: Patient Perspectives [ID: 1337224

INTRODUCTION: Historically, procedural education on pelvic exams has included students performing them on anesthetized gynecologic surgical patients—oftentimes, without the patient's explicit consent. What constitutes acceptable consent in this situation? We surveyed patients on minimally acceptable methods of obtaining verbal consent for a medical student to perform a pelvic exam while a patient is under general anesthesia (EUA). METHODS: Our study population was Vanderbilt University Medical Center gynecology outpatients 18+ who had no history of gynecologic surgery under anesthesia nor planned surgery of this kind in the future. Patients were screened for eligibility via chart and then approached at clinic. If they agreed to participate, they received a secure REDCap survey to submit an anonymous response. RESULTS: Overall, 31 patients received surveys and 21 responses were collected (response rate 67%). Results demonstrated patients are willing to participate in educational exams and consider informed consent via verbal discussion to be critically important. Among these respondents there was consensus the surgeon is the ideal person to lead discussion. A resident was acceptable, but a medical student alone was considered unacceptable by significant portion of respondents (38.1%). Free text responses indicated chaperoning or supervision of a medical student was of great importance, both during consent process and exam. Respondents indicated multiple time points (before and day of surgery) and locations (office and in hospital) were ideal, but day of surgery was acceptable. Finally, there was consensus language used to describe the exam should be specific and detailed; generalizations or omissions were considered unacceptable, not just unideal. CONCLUSION: Responses suggest informed consent discussion before pelvic EUA with student and supervising educator present is highly important to these participants and should be as detailed and specific as possible. Additionally, these results agree with prior evidence that this discussion would not likely cause patients to decline to participate in EUAs.

The past, present, and future of opioid prescribing: Perioperative opioid use in gynecologic oncology patients after laparotomy at a single institution from 2012 to 2021

ObjectiveTo describe the evolution of perioperative opioid management in gynecologic oncology patients after open surgeries and determine current opioid over-prescription rates. MethodsPart one of this two-part study was a retrospective chart review of adult patients who underwent laparotomy by a gynecologic oncologist from July 1, 2012 to June 30, 2021, comparing changes in clinical characteristics, pain management and discharge opioid prescription sizes between fiscal year 2012 (FY2012) and 2020 (FY2020). In part two, we prospectively surveyed patients after laparotomy in 2021 to determine opioid use after hospital discharge. Results1187 patients were included in the chart review. Demographic and surgical characteristics remained stable from FY2012 to FY2020 with differences notable for increased rates of interval cytoreductive surgeries for advanced ovarian cancer and decreased rates of full lymph node dissection. Median inpatient opioid use decreased by 62 % from FY2012 to FY2020. Median discharge opioid prescription size was 675 oral morphine equivalents (OME) per patient in FY2012 and decreased by 77.7 % to 150 OME in FY2020. Of 95 surveyed patients in 2021, median self-reported opioid use after discharge was 22.5 OME. Patients had an excess of opioids equivalent to 1331 doses of 5-milligram oxycodone tablets per 100 patients. ConclusionInpatient opioid use in our gynecologic oncology open surgical patients and post-discharge opioid prescription size significantly decreased over the last decade. Despite this progress, our current prescribing patterns continue to significantly overestimate patients’ actual opioid use after hospital discharge. Individualized point of care tools are needed to determine an appropriate opioid prescription size.

Corrected flow time and respirophasic variation in blood flow peak velocity of radial artery predict fluid responsiveness in gynecological surgical patients with mechanical ventilation

BackgroundRecent evidence suggests that ultrasound measurements of carotid and brachial artery corrected flow time (FTc) and respirophasic variation in blood flow peak velocity (ΔVpeak) are valuable for predicting fluid responsiveness in mechanical ventilated patients. We performed the study to reveal the performance of ultrasonic measurements of radial artery FTc and ΔVpeak for predicting fluid responsiveness in mechanical ventilated patients undergoing gynecological surgery.MethodsA total of eighty mechanical ventilated patients were enrolled. Radial artery FTc and ΔVpeak, and non-invasive pulse pressure variation (PPV) were measured before and after fluid challenge. Fluid responsiveness was defined as an increase in stroke volume index (SVI) of 15% or more after the fluid challenge. Multivariate logistic regression analyses and receiver operating characteristic (ROC) curve were used to screen multivariate predictors of fluid responsiveness and identify the predictive abilitie of non-invasive PPV, ΔVpeak and FTc on fluid responsiveness.ResultsForty-four (55%) patients were fluid responders. Multivariate logistic regression analysis showed that radial artery FTc, ΔVpeak, and non-invasive PPV were the independent predictors of fluid responsiveness, with odds ratios of 1.152 [95% confidence interval (CI) 1.045 to 1.270], 0.581 (95% CI 0.403 to 0.839), and 0.361 (95% CI, 0.193 to 0.676), respectively. The area under the ROC curve of fluid responsiveness predicted by FTC was 0.802 (95% CI, 0.706–0.898), and ΔVpeak was 0.812 (95% CI, 0.091–0.286), which were comparable with non-invasive PPV (0.846, 95%CI, 0.070–0.238). The optimal cut-off values of FTc for fluid responsiveness was 336.6 ms (sensitivity of 75.3%; specificity of 75.9%), ΔVpeak was 14.2% (sensitivity of 88.2%; specificity of 67.9%). The grey zone for FTc was 313.5–336.6 ms and included 40 (50%) of the patients, ΔVpeak was 12.2–16.5% and included 37(46%) of the patients.ConclusionsUltrasound measurement of radial artery FTc and ΔVpeak are the feasible and reliable methods for predicting fluid responsiveness in mechanically ventilated patients.Trial registrationThe trial was registered at the Chinese Clinical Trial Registry (ChiCTR)(www.chictr.org), registration number ChiCTR2000040941.

Prevalence of pre-operative anemia and associated blood transfusion among obstetrics & gynecological patients in Enugu

Background: One of the major preparations before any surgery is to ensure that the patient has adequate blood levels. Anemia, according to the WHO is a common condition in which the number of red cells (and consequently their oxygen carrying capacity) is insufficient to meet the body’s physiological needs. It is diagnosed as hemoglobin concentration of less than 11g/dl and 12g/dl in pregnant and non-pregnant women respectively. However, Nigerian women with hemoglobin levels between 10g/dl and 11g/dl go through pregnancy and surgeries without any apparent ill effects. Aim: To determine the prevalence of pre-operative anemia and associated transfusion among gynecological and obstetric surgical patients in a tertiary hospital Materials & Methods: This a retrospective study of 596 patients who had surgeries in the obstetric and gynecological department of ESUT in 2021 due to various obstetric or gynecological indications. Data was collected with a structured proforma and analyzed using Statistical Package for Social Sciences computer software for Windows version 20.0 presented in tables, charts, means, frequencies and percentages. Results: The results of the data analysis are presented in the tables below. Table 1 showed the distribution of the patients according to their age, marital status and occupation. Majority of the patients,209(35%) were above 36 years whereas 141(23.7%) were less than 25 years. Four hundred and three (67.7%) were married whereas 51(8.6) were widowed. Of all 320(53.7) were self-employed whereas 115(19.3%) were unemployed.

Efficacy and safety of a restrictive blood transfusion protocol in gynecologic surgical patients

ObjectivesThis study sought to compare differences in blood transfusion and surgical complication rates before and after the implementation of a restrictive blood transfusion protocol. MethodsOn July 1, 2018, our institution implemented a restrictive blood transfusion protocol utilizing a hemoglobin trigger of less than 7 g/dL. Retrospective chart review was completed to review patients undergoing major abdominal surgery by the gynecology and gynecologic oncology services 18 months before, and after initiation of the transfusion protocol. Outcomes included number of patients, units transfused and postoperative complication rates. Complications included reoperation on the day of admission, surgical site infections, wound disruptions, pulmonary, renal, central nervous system, and cardiovascular complications, as well as deep venous thromboses, readmissions, and 30-day mortality. ResultsThere were 290 people in the pre- and 449 patients in the post-protocol group. A similar number of patients received blood transfusions in both groups (9.3% versus 10.6% p = 0.57). However, significantly fewer units of blood were given post-protocol initiation. For every patient who received a transfusion pre-protocol, 2.66 units were administered compared to 1.2 units after the protocol was initiated (p = 0.003). All postoperative complications were not significantly different between groups (p > 0.05). Individual postoperative complications were combined and analyzed using a clustered approach to detect rates of complications more conservatively. Both the 7-system (5.1% versus 4.9%, p = 0.90) and 8-system (5.5% versus 4.9%, p = 0.72) clustered analyses were not significantly different before and after the initiation of the transfusion protocol. ConclusionsA restrictive transfusion protocol is effective in decreasing the number of units of blood transfused without affecting postoperative complication rates in gynecologic surgery patients.

Tranexamic acid: Beyond antifibrinolysis.

Tranexamic acid (TXA) is a popular antifibrinolytic drug widely used in hemorrhagic trauma patients and cardiovascular, orthopedic, and gynecological surgical patients. TXA binds plasminogen and prevents its maturation to the fibrinolytic enzyme plasmin. A number of studies have demonstrated the broad life-saving effects of TXA in trauma, superior to those of other antifibrinolytic agents. Besides preventing fibrinolysis and blood loss, TXA has been reported to suppress posttraumatic inflammation and edema. Although the efficiency of TXA transcends simple inhibition of fibrinolysis, little is known about its mechanisms of action besides the suppression of plasmin maturation. Understanding the broader effects of TXA at the cell, organ, and organism levels are required to elucidate its potential mechanisms of action transcending antifibrinolytic activity. In this article, we provide a brief review of the current clinical use of TXA and then focus on the effects of TXA beyond antifibrinolytics such as its anti-inflammatory activity, protection of the endothelial and epithelial monolayers, stimulation of mitochondrial respiration, and suppression of melanogenesis.

Valerian and postoperative sleep: a retrospective cohort analysis of gynecological, urologic, and general surgical patients.

Postoperative sleep disturbances appear to be a common complication after surgery being treated with sleep-promoting medication such as valerian, but robust data and evidence of medicinal approaches are lacking. We performed a retrospective cohort analysis of all 21 168 urological, gynecological, and general surgical patients of the University Medical Center Freiburg, Germany, who underwent surgery between 2015 and 2020. Target parameters were the usage of sleep-promoting medication to estimate the occurrence of postoperative sleep disturbances as well as the kind of sleep medication with a special focus on herbal medication such as valerian. Drug-treated sleep disturbances occurred in 15% (n = 3083) of the patients. Valerian was the second most applied drug (n = 814, 26.4%) after classic benzodiazepines (n = 1 138, 36.9%). The majority of patients got valerian as monotherapy. Age, length of stay, and comorbidities were associated with demand for sleep medication in general (p < .001). Valerian monotherapy was more common in women (OR 1.53, 95% CI: 1.33-1.77, p < .001), elderly patients (OR 1.50, 95% CI: 1.29-1.75, p < .001), and patients with prolonged hospital stay (OR 2.23, 95% CI: 1.91-2.61, p < .001). Valerian plays an important role in the treatment of postoperative sleep disturbances clinically, and it appears to be a promising therapeutic approach especially in women, older and sicker patients, and those with prolonged hospital stay. Further research has to clarify the efficacy of valerian postoperatively. DRKS00027903, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00027903.

Deep versus Moderate Neuromuscular Blockade in Gynecologic Laparoscopic Operations: Randomized Controlled Trial.

Background: To investigate whether deep neuromuscular blockade (NMB) improves surgical conditions and postoperative pain compared to moderate block, in patients undergoing gynecologic laparoscopic surgery. Methods: A single blind, randomized, controlled trial was undertaken with laparoscopic gynecologic surgical patients, who were randomly assigned to one of the following two groups: patients in the first group received deep NMB (PTC 0-1) and in the other, moderate NMB (TOF 0-1). Primary outcomes included assessing the surgical conditions using a four-grade scale, ranging from 0 (extremely poor) to 3 (optimal), and patients’ postoperative pain was evaluated with a five-grade Likert scale and the analgesic consumption. Results: 144 patients were analyzed as follows: 73 patients received deep NMB and 71 moderate NMB. Mean surgical field scores were comparable between the two groups (2.44 for moderate vs. 2.68 for deep NMB). Regarding postoperative pain scores, the patients in the deep NMB experienced significantly less pain than in the group of moderate NMB (0.79 vs. 1.58, p < 0.001). Moreover, when the consumption of analgesic drugs was compared, the moderate NMB group needed more extra opioid analgesia than the deep NMB group (18.3% vs. 4.1%, p = 0.007). From the secondary endpoints, an interesting finding of the study was that patients on deep NMB had significantly fewer incidents of subcutaneous emphysema. Conclusions: Our data show that, during the performance of gynecologic laparoscopic surgery, deep NMB offers no advantage of operating filed conditions compared with moderate NMB. Patients may benefit from the deep block as it may reduce postoperative pain.

Efficacy and safety of institution-wide restrictive blood transfusion protocol in gynecologic surgical patients

The use of restrictive blood transfusion protocols has been well documented in specific patient populations, however there is little data in the field of gynecology. The objective of this study was to compare differences in blood transfusion rates and surgical complications before and after the implementation of a restrictive transfusion protocol. The target population included patients undergoing major abdominal surgery by both gynecologists and gynecologic oncologists at a university hospital.

Preoperative low-residue diet in gynecological surgery

ObjectiveTo evaluate the impact of preoperative low-residue diet on intra- and postoperative outcomes among gynecological surgical patients. MethodsThis is a surgeon-blind, randomized controlled trial enrolling patients undergoing elective surgery for either benign disease or endometrial carcinoma. Patients were preoperatively randomized to receive either low-residue diet (arm A) or free diet (arm B) starting from three days before surgery. The primary outcome was the quality of the surgical field (scored using a 5-point scale, from poor to excellent). Secondary outcomes were postoperative pain (assessed through VAS scale), postoperative complications, operative time, time to first passage of flatus, length of hospital stay. Perioperative data were collected and compared between groups. ResultsA total of 96 patients were enrolled and randomized in arm A (n = 49; 51%) and arm B (n = 47; 49%). The mean age was 47.8 ± 15.6 years in arm A and 48.1 ± 11.3 years in arm B. Endometrial cancer patients were 16.3% in arm A and 10.6% in arm B, and patients with benign disease were 83.7% and 89.4%, respectively. The surgical evaluation of the small intestine was scored < 3 in 2.0% of arm A patients versus 31.9% in arm B (Odds Ratio (OR), 0.04 [95% CI, 0.01–0.35]; p < 0.001), and in 6.1% and 44.7% (OR, 0.08 [95% CI, 0.02–0.30]; p < 0.001), respectively, for large intestine. The mean operative time was 90.4 ± 33.4 min in arm A versus 111.6 ± 37.5 in arm B (Mean Difference (MD): −21.20 [95% CI, −35.43, −6.97]; p = 0.003). The number of patients who reported the time to first flatus within 24 h after surgery was significantly higher in arm A compared with arm B (77.6% vs 44.7%; OR, 4.28 [95% CI, 1.77–10.35]; p = 0.002). No significant differences in terms of postoperative complications, pain, and length of hospital stay were observed between the two groups. ConclusionIntroducing a preoperative low-residue diet could improve the quality of the surgical field and reduce both the operative duration and the time to first passage of flatus among patients undergoing gynecological surgery. Further large-scale studies are required to confirm these findings.

Validation of two risk assessment models for venous thromboembolism in patients undergoing gynecologic surgery.

BackgroundAccording to published guidelines, gynecologic surgical patients should be stratified into different risk level groups to receive prophylaxis for venous thromboembolism (VTE), but the applicability of available risk assessment models (RAMs) in common gynecologic surgical patients remained to be confirmed. We aimed to validate the use of the Caprini RAM and gynecologic Caprini (G-Caprini) RAM for assessing postoperative VTE risk in gynecologic surgical patients.MethodsThe database of a randomized controlled trial (RCT) was used to select patients who underwent gynecologic surgeries for benignant and malignant diseases in five institutions in China between 2011 and 2018. The Caprini RAM version recommended by the American College of Chest Physicians (ACCP) was adopted. Participants were divided into four risk levels based on the Caprini and G-Caprini scores. For each risk level group, the incidence of VTE was calculated. The correlation between VET incidence and risk levels was assessed by Spearman’s rank correlation coefficient (RS) value.ResultsAs a result, 800 patients in the data base were analyzed with an overall VTE incidence of 5.8%. Caprini RAM showed that the percentage of patients at very low risk, low risk, moderate risk, and high risk were 0%, 4.3%, 44.4%, and 51.4%, respectively, and the VTE incidence was 2.9%, 2.3%, and 9.0%, respectively. RS value between the risk stratification and VTE incidence was 0.500 (P=0.667). G-Caprini RAM showed that the percentage of patients at very low risk, low risk, moderate risk, and high risk were 7.8%, 28.0%, 32.0%, and 32.3%, respectively, and the VTE incidence was 0.0%, 2.9%, 2.3%, and 9.0%, respectively. RS value between the risk stratification and VTE incidence was 1.000 (P<0.01).ConclusionsThe G-Caprini RAM was as suitable as the Caprini RAM for VTE risk assessment in gynecologic surgical patients. The gynecologic model has the advantages of ease of use and more accurate identification of low-risk groups.

Using an Environmentally Friendly Disposal Bag to Discard Leftover Opioids After Gynecologic Surgery.

To evaluate the effects of an environmentally friendly drug deactivation bag on opioid disposal among patients undergoing gynecologic surgery. This prospective cohort study included patients undergoing gynecologic procedures requiring an opioid prescription from March 2020 to December 2020. Patients were managed on a restrictive opioid prescribing algorithm and given an opioid disposal bag. The carbon drug deactivation bag neutralizes the opioid medication and can be discarded safely in the trash. Patients were educated about pain management goals and the disposal bag. Patients were surveyed at their postoperative visit to evaluate satisfaction, number of leftover pills, and disposal methods. Statistical analysis was performed using SPSS Statistics 26. Two hundred patients were asked to complete the survey, with a response rate of 78%. The most common procedures were exploratory laparotomy (50%) and minimally invasive hysterectomy (41%). Most patients (91%, 95% CI 91-97) filled their opioid prescription and 64 (41%, 95% CI 34-48) had leftover opioid pills. Most patients with leftover opioid pills (73%, 95% CI 67-79) discarded them; 78%, 95% CI 69-80 used the disposal bag. Patients undergoing an exploratory laparotomy most commonly used the disposal bag. All patients who used the disposal bag stated they would use it again. Despite a restrictive opioid prescribing algorithm, 41% of gynecologic surgical patients had leftover opioid pills. This study demonstrated that leftover opioid pills were safely discarded 73% of the time when patients were provided an opioid disposal bag and preoperative education.

Postdischarge Nausea and Vomiting Risk Assessment in Breast and Gynecological Surgical Patients

Introduction Postdischarge nausea, vomiting or retching (PDNV) occurs after the time of discharge from the post anesthesia care unit (PACU) for patients who have undergone out-patient surgeries. Consequences include increased healthcare costs, rehospitalizations, and decreased patient satisfaction. Identification of the Problem At a large mid-Atlantic academic hospital, 40% of gynecological out-patient surgical patients had PDNV as identified by a separate quality improvement project. EBP Question/Purpose The PICO question guiding the project was: In out-patient surgical populations, does the implementation of a PDNV risk assessment tool improve early identification of patients at risk for PDNV? Databases utilized included PubMed, Ovid MEDLINE and CINAHL. The purpose of this quality improvement project was to implement and evaluate the effectiveness of and staff compliance with the Apfel Postdischarge Nausea and Vomiting Risk Assessment tool in order to improve PDNV screening in the PACU. Methods/Evidence As part of Lewin's Change Theory, key stakeholders and unit champions, were recruited. All PACU registered nurses received education on the risk assessment protocol utilizing the Apfel risk assessment tool. The Apfel risk assessment tool is validated to identify five independent risk factors for PDNV in out-patient ambulatory surgical populations. Implementation of the tool with data collection occurred over eight weeks on all scheduled out-patient breast and gynecological surgical patients. Staff compliance was measured throughout implementation. Significance of Findings/Outcomes In patients with at least three risk factors present, the Apfel tool correctly identified the risk for PDNV in 68% of patients. In patients with four and five risk factors present, the tool correctly identified the risk for PDNV in 88% and 100% of patients respectively. Compliance of the tool was high with the average compliance rate of 92% over the eight-week data collection period. Additional outcomes included improved follow up phone call completion rate, and increased administration of preventative pharmacological interventions in patients at high risk for PDNV. Implication for Perianesthesia Nurses and Future Research The Apfel tool adequately predicted the risk for PDNV in out-patient surgical breast and gynecological patients. Lewin's change theory was successful in maintaining a high compliance rate throughout implementation. Efforts toward sustainment include expansion to all out-patient surgical populations and implementation of a PDNV prevention and management guideline. Postdischarge nausea, vomiting or retching (PDNV) occurs after the time of discharge from the post anesthesia care unit (PACU) for patients who have undergone out-patient surgeries. Consequences include increased healthcare costs, rehospitalizations, and decreased patient satisfaction. At a large mid-Atlantic academic hospital, 40% of gynecological out-patient surgical patients had PDNV as identified by a separate quality improvement project. The PICO question guiding the project was: In out-patient surgical populations, does the implementation of a PDNV risk assessment tool improve early identification of patients at risk for PDNV? Databases utilized included PubMed, Ovid MEDLINE and CINAHL. The purpose of this quality improvement project was to implement and evaluate the effectiveness of and staff compliance with the Apfel Postdischarge Nausea and Vomiting Risk Assessment tool in order to improve PDNV screening in the PACU. As part of Lewin's Change Theory, key stakeholders and unit champions, were recruited. All PACU registered nurses received education on the risk assessment protocol utilizing the Apfel risk assessment tool. The Apfel risk assessment tool is validated to identify five independent risk factors for PDNV in out-patient ambulatory surgical populations. Implementation of the tool with data collection occurred over eight weeks on all scheduled out-patient breast and gynecological surgical patients. Staff compliance was measured throughout implementation. In patients with at least three risk factors present, the Apfel tool correctly identified the risk for PDNV in 68% of patients. In patients with four and five risk factors present, the tool correctly identified the risk for PDNV in 88% and 100% of patients respectively. Compliance of the tool was high with the average compliance rate of 92% over the eight-week data collection period. Additional outcomes included improved follow up phone call completion rate, and increased administration of preventative pharmacological interventions in patients at high risk for PDNV. The Apfel tool adequately predicted the risk for PDNV in out-patient surgical breast and gynecological patients. Lewin's change theory was successful in maintaining a high compliance rate throughout implementation. Efforts toward sustainment include expansion to all out-patient surgical populations and implementation of a PDNV prevention and management guideline.

Care as Usual: An Acceptable Strategy to Apply During the COVID-19 Pandemic in a French Tertiary Gynecologic Oncology Department.

We describe and analyze a “care as usual” strategy of a French Comprehensive Cancer Center during the COVID-19 pandemic to manage surgical patients with gynecological cancer. We conducted a retrospective analysis evaluating the surgical activity in our gynecologic oncology department between January 21 and May 12, 2020. We compared the surgical activity and surgical and oncologic outcomes during the pre-lockdown period and the pandemic period. The main objective was to evaluate the impact of the COVID-19 pandemic on surgical activity. The secondary objectives were to analyze the surgical and the oncologic outcomes. We compared the surgical activity during the 8 weeks after the national lockdown (85 procedures) to the surgical activity in the 8 weeks preceding the lockdown (127 procedures). We observed a 33% decrease in activity between the two periods. The clinical and epidemiologic characteristics were similar between the two periods. There were no differences between the surgical approaches (p = 0.592), the surgical complexity (p = 0.323), the length of stay (p = 0.85), and even for the complex procedure (p = 0.96) and the perioperative (p = 0.791) and postoperative complication rates (p = 0.102). We observed a significant decrease in the time of return to intended oncological treatment (RIOT) during the lockdown period with an average of 31.9 days compared to 46.9 days in the pre-lockdown period (p = 0.003). During the COVID-19 pandemic, “care as usual” represents an acceptable strategy without impairing the oncologic outcome in a Comprehensive Cancer Center with a patient-centered clinical pathway for gynecologic oncologic surgical patients.

Postdischarge Nausea and Vomiting Risk Assessment in Breast and Gynecologic Surgical Patients

PurposePostdischarge nausea, vomiting, and retching often occur after the time of discharge from the postanesthesia care unit (PACU) in patients who have undergone outpatient surgeries. At a large mid-Atlantic Academic Hospital, 40% of gynecologic outpatient surgical patients had postdischarge nausea and vomiting (PDNV). The purpose of this quality improvement project was to implement and evaluate the effectiveness of and staff compliance with the Apfel Postdischarge Nausea and Vomiting Risk Assessment tool to improve PDNV risk screening in the PACU. DesignThis quality improvement project was part of an evidence-based practice project. MethodsAfter identification and recruitment of key stakeholders and unit champions, a force-field analysis, as part of Lewin's change theory, was completed to identify the driving and restraining forces. All PACU registered nurses received education on the risk assessment protocol using the Apfel risk assessment tool. The Apfel risk assessment tool has been validated to identify five independent risk factors for PDNV in outpatient ambulatory surgical populations. Implementation of the tool with data collection occurred for 8 weeks on all scheduled outpatient breast and gynecologic surgical patients. Staff compliance was measured throughout implementation. FindingsIn patients with at least three risk factors present, the Apfel tool correctly identified the risk for PDNV in 68% of patients. In patients with four and five risk factors present, the tool correctly identified the risk for PDNV in 88% and 100% of patients, respectively. Compliance with the tool was high with an average compliance rate of 92% for the 8-week data collection period. ConclusionsData analysis demonstrated that the Apfel risk assessment tool adequately predicted the risk for PDNV in outpatient surgical breast and gynecologic patients. Use of Lewin's change theory was successful in maintaining a high compliance rate throughout implementation. In addition, this quality improvement project resulted in increased compliance of the standing follow-up phone call policy. Efforts toward sustainment include expansion to all outpatient surgical populations and implementation of a PDNV prevention and management guideline.

Mechanical bowel preparation before gynecologic laparoscopic procedures: Is it time to abandon this practice?

To examine the influence of mechanical bowel preparation on surgical field visualization and patients' quality of life during benign gynecologic laparoscopic procedures. A single blind, randomized, controlled trial was undertaken with laparoscopic gynecologic surgical patients to one of the following three groups: liquid diet on the preoperative day; mechanical bowel preparation with oral polyethylene glycol (PEG) solution; minimal residue diet for 3 days. Primary outcomes included assessment of the condition of small and large bowel and the overall quality of the surgical field. Additional measures included assessment of patients' preoperative symptoms, tolerance of the preparation method and compliance to the protocol, postoperative symptoms and bowel function. One hundred forty-four patients were randomized as follows: 49 to liquid diet, 47 to mechanical bowel preparation, and 48 to minimal residue diet. Most characteristics were similar across groups. The intraoperative surgical view and the condition of large and small bowel were equal or inferior at the patients who received mechanical bowel preparation compared with the other groups. The 4-point Likert scale scoring for small bowel (2.51 vs. 2.72 vs. 2.81, p = 0.04), large bowel (2.26 vs. 2.38 vs. 2.48, p = 0.32) and overall operative field quality (2.34 vs. 2.67 vs. 2.67, p = 0.03) demonstrated no advantage from the use of preoperative mechanical bowel preparation over liquid diet and minimal residue diet, respectively. Preoperative discomfort was significantly greater in the mechanical bowel preparation group. Mechanical bowel preparation before gynecologic laparoscopic operations for benign pathology could be safely abandoned. ISRCTN registry, https://doi.org/10.1186/ISRCTN59502124 (No 59502124).