Major Gynaecological Surgery Research Articles

Calculating surgical readmission rates in gynecologic oncology: The impact of patient factors

ObjectiveTo determine the 30-day surgical readmission rate after major gynecologic oncology surgeries at a high-volume academic institution and correlated risk factors. MethodsRetrospective cohort study was conducted of surgical admissions from January 2016 – December 2019 at a single institution. Data were extracted from patient charts, including reason for readmission and length of stay. A readmission rate was calculated. Nested case control design was used to identify correlations between readmission and patient specific risk-factors. Multivariable logistic regression models were used to determine risk factors with readmission. ResultsA total of 2152 patients were included. The readmission rate was 3.5%, most commonly due to GI disturbance and surgical site infection. Average readmission length was 5 days. Prior to adjusting for covariates, insurance status, primary diagnosis, index admission length, and disposition at discharge differed between patients who were and were not readmitted. After adjusting for co-variates, younger patients, index admission >2 days, and higher Charlson co-morbidity index were associated with readmission. ConclusionsOur surgical readmission rate was lower than previously reported rates in gynecologic oncology patients. Patient factors associated with readmission included younger age, longer index hospital admission, and higher medical co-morbidity index scores. Provider factors and institutional practice patterns could contribute to the decreased readmission rate. These findings underscore the importance of standardizing how we calculate readmission rate and interpret these data. Varying readmission rates and institutional practice patterns deserve closer scrutiny to inform best practice and future policies.

Urological problems among women with major gynecological surgeries at a tertiary hospital in Port Harcourt, Nigeria.

Introduction: Urological problems are common in women, especially those undergoing surgeries, due to the proximity of the urinary tract and the reproductive tract. This study aims to present the complications of major gynecological surgeries in our institution. Materials and Methods: This study reviewed sixty-one case notes of patients who had gynecologic surgeries at Rivers State University Teaching Hospital, Port Harcourt. The data were analyzed using SPSS, and the results were presented in tables and charts. Results: The mean age of the patients was 38.51 years. Forty-eight (78.7%) had myomectomy; 8.2% total had an abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH+BSO); and 4.9% had ovarian cystectomy. Those with pelvic tumors were 78.7%, and tumors with hypertension were 14.8%. Eight patients (13.1%) had urinary tract infections, while 7 (11.5%) had abnormal abdominal ultrasound findings, and 3.3% had abnormal renal function with serum creatinine above 120 micromoles per liter. Urinary tract infections were the most common urological problem among the women. Risk factors for urological problems were pelvic tumors (mostly uterine fibroids), hypertension, previous pelvic surgeries, and uterovaginal prolapse. Seven patients had lower urinary tract symptoms. Frequency of micturition and dysuria were the most common urinary tract symptoms. Conclusion: The most common lesions were urinary tract infections. Findings made here differ from those of other studies in which findings were mostly of iatrogenic urological injuries. The most common risk factors were pelvic tumors which caused mechanical obstruction to the urine flow. Early detection and treatment of pelvic tumors and hypertension are advocated in this population.

Prescription Opioid Use for Acute Pain and Persistent Opioid Use After Gynecologic Surgery: A Systematic Review.

To assess the amount of opioid medication used by patients and the prevalence of persistent opioid use after discharge for gynecologic surgery for benign indications. We systematically searched MEDLINE, EMBASE, and ClinicalTrials.gov from inception to October 2020. Studies with data on gynecologic surgical procedures for benign indications and the amount of outpatient opioids consumed, or the incidence of either persistent opioid use or opioid-use disorder postsurgery were included. Two reviewers independently screened citations and extracted data from eligible studies. Thirty-six studies (37 articles) met inclusion criteria. Data were extracted from 35 studies; 23 studies included data on opioids consumed after hospital discharge, and 12 studies included data on persistent opioid use after gynecologic surgery. Average morphine milligram equivalents (MME) used in the 14 days after discharge were 54.0 (95% CI 39.9-68.0, seven tablets of 5-mg oxycodone) across all gynecologic surgery types, 35.0 (95% CI 0-75.12, 4.5 tablets of 5-mg oxycodone) after a vaginal hysterectomy, 59.5 (95% CI 44.4-74.6, eight tablets of 5-mg oxycodone) after laparoscopic hysterectomy, and 108.1 (95% CI 80.5-135.8, 14.5 tablets of 5-mg oxycodone) after abdominal hysterectomy. Patients used 22.4 MME (95% CI 12.4-32.3, three tablets of 5-mg oxycodone) within 24 hours of discharge after laparoscopic procedures without hysterectomy and 79.8 MME (95% CI 37.1-122.6, 10.5 tablets of 5-mg oxycodone) from discharge to 7 or 14 days postdischarge after surgery for prolapse. Persistent opioid use occurred in about 4.4% of patients after gynecologic surgery, but this outcome had high heterogeneity due to variation in populations and definitions of the outcome. On average, patients use the equivalent of 15 or fewer 5-mg oxycodone tablets (or equivalent) in the 2 weeks after discharge after major gynecologic surgery for benign indications. Persistent opioid use occurred in 4.4% of patients who underwent gynecologic surgery for benign indications. Our findings could help surgeons minimize overprescribing and reduce medication diversion or misuse. PROSPERO, CRD42020146120.

Pelvic floor muscle training: Novel versus traditional remote rehabilitation methods. A systematic review and meta-analysis on their effectiveness for women with urinary incontinence.

To investigate the effectiveness of supervised remote rehabilitation programs comprising novel methods of pelvic floor muscle (PFM) training for women with urinary incontinence (UI). A systematic review and meta-analysis including randomized controlled trials (RCTs), involving novel supervised PFM rehabilitation programs as intervention groups (e.g., mobile applications programs, web-based programs, vaginal devices) versus more traditional PFM exercise groups (acting as control); both sets of groups being offered remotely. Data have been searched and retrieved from the electronic databases of Medline, PUBMED, and PEDro using relevant key words and MeSH terms. All included study data were handled as reported in the Cochrane Handbook for Systematic Reviews of Interventions and the evaluation of their quality was undertaken utilizing the Cochrane risk-of-bias tool 2 (RoB2) for RCTs. The included RCTs, involved adult women with stress UI (SUI) or mixed urinary incontinence, where SUI were the most predominant symptoms. Exclusion criteria involved pregnant women or up to 6-month postpartum, systemic diseases and malignancies, major gynecological surgeries or gynecological problems, neurological dysfunction or mental impairments. The searched outcomes included subjective and objective improvements of SUI and exercise adherence in PFM exercises. Meta-analysis was conducted and included studies pulled by the same outcome measure. The systematic review included 8 RCTs with 977 participants. Novel rehabilitation programs included mobile applications (1 study), web-based programs (1 study) and vaginal devices (6 studies) versus more traditional remote PFM training, involving home-based PFM exercise programs (8 studies). Estimated quality with Cochrane's RoB2, presented the 80% of the included studies as "some concerns" and the 20% as "high risk." Meta-analysis included 3 studies with no heterogeneity (I2 = 0) across them. Weak-evidenced results presented home PFM training equally effective with novel PFM training methods (mean difference: 0.13, 95% confidence interval: -0.47, 0.73), with small total effect size (0.43). Novel PFM rehabilitation programs presented as effective (but not superior) to traditional ones in women with SUI, both offered remotely. However, individual parameters of novel remote rehabilitation including supervision by the health professional, remains in question and larger RCTs are required. Connection between devices and applications in combination with real-time synchronous communication between patient and clinician during treatment is challenged for further research across novel rehabilitation programs.

Comparative Evaluation of Haemodynamic Effects of Continuous Versus Intermittent Epidural Injections of Bupivacaine with Fentanyl for Major Gynaecological Surgeries

Background: Epidural anaesthesia can be administered as single shot, intermittently, continuously or as patient controlled injection. Our study compared the intraoperative haemodynamic effects of continuous versus intermittent epidural injections of bupivacaine with fentanyl for major gynaecological surgeries.

First experiences with a diode laser in major gynecological laparoscopic procedures show lack of benefit and impaired feasibility

PurposeThe aim of this study is to evaluate feasibility and potential benefit of a diode laser in major laparoscopic procedures in gynecology.MethodsBetween 2018 and 2020, a total of 42 cases were enrolled in this study comparing standard electrosurgery with diode laser-supported therapy in laparoscopic supracervical hysterectomy (LASH), total laparoscopic hysterectomy (TLH), or laparoscopic myoma enucleation (LME). Dual wavelength 45 W diode laser light was used to cut and coagulate during laparoscopy in the prospective interventional arm consisting of 11 cases, while 31 matching patients who received conventional treatment with monopolar/bipolar current for the same interventions were retrospectively identified in our laparoscopy database. Recruitment in the prospective interventional laser diode arm was terminated after only 11 patients (instead of planned 50) due to intense hemorrhage and massive smoke development.ResultsA total of 42 cases were analyzed (11 LME, 19 LASH, and 12 TLH). Strong smoke development was evident in all 11 cases in the diode laser arm. It was necessary to convert to bipolar or monopolar current in all hysterectomies (n = 9) with initial diode laser implementation due to increased bleeding and smoke development. Conventional current sources had to be used in LMEs (n = 2) due to excessive bleeding and poor visibility during enucleation of the fibroid. A significant difference (p < 0.0001) was observed regarding smoke development when comparing the laser arm with the control arm.ConclusionWe found a 45-W diode laser to be inferior to electrosurgical techniques for major laparoscopic gynecologic surgeries regarding bleeding control and smoke development.

Impact of Counselling and Consent on Patient’s Satisfaction at a Tertiary Care Hospital in Karachi, Sindh

Background: Detail counseling of the patient helps them to understand the importance of treatment and improves their compliance. It also improves the relationship between the doctor and the patient. Objective: Current study aims to determine the patient satisfaction level going for major gynecological surgery by detailed counseling and consent. Material and Methods: This is a cross-sectional study conducted at Liaquat National Hospital, Karachi. The duration of the study was one year (1st march 2018 to 28 February 2019). Informed consent was taken from participants fulfilling the inclusion criteria. The questionnaire was composed of demographic details of patients such as age, gender, marital status, education level, and socioeconomic status. The satisfaction rating scale was used to assess the impact of counseling on the patient. The scale contains different items regarding counseling and consent that assesses patient satisfaction, rated on a 1–5 scale (1 = strongly disagree; 5 = strongly agree). Higher scores indicate higher satisfaction. Results: In our study majority of the participants were from 41-50 (30%) years of age, and all were married and belonging to the middle class. The majority were from the secondary level which is 62%. Out of 156 participants, 87 agreed that counsellor listened to them, 96 understood the information, 91 were comfortable talking to the counsellor and 80 were more hopeful about their progress. Similarly, the majority of the participants agreed and were satisfied with the treatment after informed consent. Results found that 85% of participants showed a higher satisfaction level towards counseling and informed consent. Conclusion: Counseling is a useful supplementary technique for refining treatment adherence and disease condition. Taking consent is the asymmetrical method to create a relationship between healthcare providers and patients.

Evaluation of t he Effectiveness of Intra-Operative Low Dose Ketamine Infusion on Post-Operative Pain Management Following Major Abdominal Gynaecological Surgeries

Evaluation of t he Effectiveness of Intra-Operative Low Dose Ketamine Infusion on Post-Operative Pain Management Following Major Abdominal Gynaecological Surgeries

The Prevalence, Indications, Outcomes of the Most Common Major Gynecological Surgeries in Kazakhstan and Recommendations for Potential Improvements into Public Health and Clinical Practice: Analysis of the National Electronic Healthcare System (2014-2019).

Major gynecological surgeries are indicated for the treatment of female genital pathologies. It is key to examine trends in gynecologic surgical procedures and updated recommendations by international gynecological societies to find opportunities for improvement of local guidelines. To date, a very limited number of reports have been published on the epidemiology of gynecological surgeries in Kazakhstan. Moreover, some local guidelines for gynecological conditions do not comply with the international recommendations. Thus, this study aims to investigate the prevalence, indications, and outcomes of the most common major gynecological surgeries by analyzing large-scale Kazakhstani healthcare data, and identifying possible opportunities for improvement of the local public health and clinical practice. A descriptive, population-based study among women who underwent a gynecological surgery in healthcare settings across the Republic of Kazakhstan during the period of 2014-2019 was performed. Data were collected from the Unified Nationwide Electronic Health System (UNEHS). In total, 80,401 surgery cases were identified and analyzed in the UNEHS database for a period of 6 years (2014-2019). The median age of the participants was 40 years old, with 61.1% in reproductive age. The most prevalent intervention was a unilateral salpingectomy-29.4%, with 72.6% patients aged between 18-34 years. The proportion of different types of hysterectomies was 49.4%. In 20% of cases, subtotal abdominal hysterectomy was performed due to uterine leiomyoma. The proportion of laparoscopic procedures in Kazakhstani gynecological practice is as low-11.59%. The Kazakhstani public health and gynecological care sector should reinforce implementation of contemporary treatment methods and up-to-date policies and guidelines. The overall trends in surgical procedures performed for gynecological pathologies, including uterine leiomyoma and ectopic pregnancy treatment, should be changed in favor of the minimally invasive methods in order to adopt a fertility-sparing approach.

Developing a new preoperative iron-deficiency anaemia service for major gynaecological surgery – improving multiple patient outcomes

Background: Preoperative anaemia is an independent predictor of poorer outcomes after surgery. Alongside this, allogeneic blood transfusion is also associated with increased complications and length of stay. Iron deficiency anaemia (IDA) is frequently found in patients undergoing major gynaecological surgery. Together with surgical blood loss, blood transfusions are therefore common. The national transfusion rate for hysterectomy is 9%.1 We recognised the need for a dedicated service for the management of preoperative IDA, developing it over several quality improvement (QIP) cycles.

Pain management in elective major gynaecology surgery: implementing an enhanced recovery protocol

Background: Enhanced recovery after surgery (ERAS) improves outcomes in major surgery.1 Optimising analgesia with a multimodal, opioid-sparing approach allows for faster recovery, reducing hospital stay, costs, and morbidity.2 We implemented a perioperative enhanced recovery protocol (ERP) in elective major gynaecological surgery and analysed its impact on pain scores, side-effects and return to baseline function. Methods: Pre-ERP implementation data were collected from December 2020 to June 2021. Post-ERP data were collected from September to December 2021. Elective gynaecology lists were screened for eligible patients (>18 yr, hysterectomy or myomectomy, open or laparoscopic). Data were prospectively collected using dedicated questionnaires (anaesthetic technique, postoperative analgesic requirement, pain scores, side-effects, and return to baseline). Results: Comparison of 37 patients pre-ERP and 25 patients post-ERP respectively revealed: (1) low pain score (<3/10) on day 1 postoperatively at rest (54% vs 64%), coughing (18% vs 28%) and moving (8% vs 24%), (2) experiencing side-effects: nausea (27% vs 12%), pruritis (16% vs 12%), drowsiness (19% vs 4%), and (3) return to baseline function: ambulating by Day 1 (76% vs 88%), oral intake by Day 1 (92% vs 100%) and discharged by Day 2 (75% vs 84%). Conclusions: After ERP implementation, patients were more likely to report lower pain scores, despite lower average opioid use, and less likely to report associated side-effects (nausea, itching, and drowsiness). Patients were also more likely to be ambulating and eating by Day 1 postoperatively and discharged by Day 2. These results highlight clinical and, potentially, cost-saving improvements. The authors sincerely thank the anaesthetic, recovery, and pain teams at Whipps Cross Hospital. Approval was obtained from the clinical governance department. 1.Patil S, Cornett EM, Jesunathadas J, et al. J Anaesthesiol Clin Pharmacol 2019; 35: S24–82.Bisch SP, Kooy J, Glaze S, et al. Int J Gynecol Cancer 2019; 29; 1372–6

Idiopathic megaureter incidentally detected during placenta accreta surgery

As ureter variations can be seen common and the most common type of is duplication. Rare type of a variation is widening of ureter which is defined as ‘megaureter’. It can be primary or secondary to an abnormality. The main cause for primary megaureter is functional while for the secondary is due to an anatomical narrowing or an inborn subvesical obstacle to urine flow from bladder. In this case, we presented 35 years old woman diagnosed with placenta accreta spectrum and fifth cesarean section. We performed cesarean hysterectomy and during the surgery, it was observed that the right ureter was severely dilated during the retroperitoneal control of surgery area. Dilatation of ureter was evaluated, and it was diagnosed as idiopathic. In conclusion, despite ureters should be checked during major gynecological surgeries, detection of a dilated ureter during surgery does not always mean an iatrogenic complication.

The analgesic efficacy of ultrasound-guided transversus abdominis plane block vs. local anesthetic infiltration technique in major gynecologic surgery: A randomized controlled trial.

Transversus abdominis plane (TAP) block and local anesthetic infiltration (LAI) technique are used as part of the multimodal analgesic regimen after abdominal surgery. Postoperative opioid consumption and analgesic efficacy was compared using TAP and LAI techniques in patients undergoing gynecologic surgery in a randomized, controlled clinical trial. Total of 135 patients scheduled for major gynecological surgeries were allocated into three groups: group T received bilateral TAP block with bupivacaine 0.25%; group I received LAI with 0.25% bupivacaine with epinephrine 5 μ/mL in the peritoneum and abdominal wall, and group C was control group. Anesthesia and postoperative analgesia were standardized. Outcome measures were cumulative and rescue tramadol consumption, numerical rating score (NRS) for pain and side effects in post-anesthesia care unit (PACU) at 4, 8, 12 hours postoperatively. Tramadol consumption, need for rescue analgesia, and NRS for pain between three groups at 4, 8, and 12 hours postoperatively had no statistically significant difference (P < 0.05). In PACU, median tramadol consumption used for rescue analgesia between group T (15 (15-30)) and group C (30 (15-45)) (P = 0.035), and between group T (15 (15-30)) and group I (30 (15-52)) was statistically significant (P = 0.034). In PACU, the percentage of patients having NRS >4 on movement in group C (72%) compared to group T (46.5%) and group I (46.5%) was significant (P = 0.034). No statistically significant difference was observed in the incidence of side effects among study groups (P > 0.05). Except for the immediate postoperative period, neither TAP block nor LAI had added benefit to the multimodal analgesia regimen in patients undergoing gynecological surgeries.

Actionable Factors Fostering Health Value Generation and Scalability of Prehabilitation: A Prospective Cohort Study.

Prehabilitation has potential for improving surgical outcomes as shown in previous randomized controlled trials. However, a marked efficacy-effectiveness gap is limiting its scalability. Comprehensive analyses of deployment of the intervention in real-life scenarios are required. To assess health outcomes and cost of prehabilitation. Prospective cohort study with a control group built using propensity score-matching techniques. Prehabilitation Unit in a tertiary-care university hospital. Candidates for major digestive, cardiac, thoracic, gynecologic, or urologic surgeries. Prehabilitation program, including supervised exercise training, promotion of physical activity, nutritional optimization, and psychological support. The comprehensive complication index, hospital and intensive care unit length of stay, and hospital costs per patient until 30 days after surgery. Patients were classified by the degree of program completion and level of surgical aggression for sensitivity analysis. The analysis of the entire study group did not show differences in study outcomes between prehabilitation and control groups (n=328 each). The per-protocol analysis, including only patients completing the program (n=112, 34%), showed a reduction in mean hospital stay [9.9 (7.2) vs 12.8 (12.4) days; P =0.035]. Completers undergoing highly aggressive surgeries (n=60) additionally showed reduction in mean intensive care unit stay [2.3 (2.7) vs 3.8 (4.2) days; P =0.021] and generated mean cost savings per patient of €3092 (32% cost reduction) ( P =0.007). Five priority areas for action to enhance service efficiencies were identified. The study indicates a low rate of completion of the intervention and identifies priority areas for re-design of service delivery to enhance the effectiveness of prehabilitation.

Risk assessment and compliance with hospital guidelines for venous thromboprophylaxis after gynecological surgeries

Background and objective: Venous thromboembolism after gynecological surgery is a major cause of morbidity and mortality. This study aimed to determine the venous thromboembolism risk profile of women who underwent gynecological surgery at a tertiary hospital and review the prescribed venous thromboembolism prophylaxis. Methods: An audit review study was conducted on 490 women who underwent major and minor gynecological surgeries at the Maternity Teaching Hospital, Erbil city, Kurdistan Region, Iraq, from 1st December 2019 to 31st December 2020, regarding their risk of developing postoperative venous thromboembolism using the 2013 modified Caprini venous thromboembolism risk assessment model to determine their risk and the correct thromboprophylaxis prescription. Results: According to appropriate thromboprophylaxis administration of low molecular weight heparin, it was administered to two-thirds of the women. It was sufficient in 33.1% of the women, and only 8.2% of the women received it for the correct duration. The probability of incorrect decision was higher for the major surgeries than for minor surgeries [odds ratio (OR) = 15.5; 95% confidence interval (95% CI) =3.01–80.1]. Moderate risk carried a much higher probability of an incorrect decision than low risk (OR = 196.8; 95%CI = 30.4–1270.5), whereas the association with high risk was not significant. When low molecular weight heparin was administered, there was a higher probability of a wrong decision than when low molecular weight heparin was not administered (OR = 26.4; 95%CI = 7.1–97.6). Conclusion: The gynecologists' adherence to venous thromboembolism prophylaxis after major and minor gynecological surgeries at the hospital mandates more training for all healthcare providers. Keywords: Audit; Thromboprophylaxis; Caprini RAM 2013; Adherence to guidelines; Gynecological surgery.

Pleth Variability Index Guided Volume Optimisation in Major Gynaecologic Surgery.

To compare conventional fluid management (CFM) with pleth variability index (PVI) guided goal-directed fluid management (GDFM) during elective total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH+BSO) operations. Randomised controlled trial. Department of Anaesthesiology and Reanimation, Faculty of Medicine, Health Sciences University, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey, from February to July 2021. This trial included 78 patients aged 18-65 years with ASA I-III who would undergo elective TAH-BSO under general anaesthesia. Following randomisation with the closed envelope method, standard monitoring, and 250 ml crystalloid infusion during anaesthesia induction, maintenance fluid therapy was administered at 8-10 ml/Kg/hour to the control group and 2-3 ml/Kg/hour to the PVI group. If the mean arterial pressure (MAP) was ≤65 mmHg and/or the MAP was decreased by more than 20%, and the PVI was >13%, a 250 ml colloid bolus was given. When there was no response, a vasoactive agent was administered. Vital signs, laboratory findings, and postoperative complications were evaluated. Age, weight, BMI, urine output, bleeding, hospital stay, comorbidities, intraoperative use of blood products, and complication rates were not significantly different between the PVI and CFM groups (p>0.05). The PVI group had shorter operational times and used less crystalloid than the control group (p=0.033 and p<0.001, respectively). The PVI group's postoperative base excess (BE) levels changed significantly less than the control group's (p<0.001). In both pre- and postoperative haemoglobin, haematocrit, urea, creatinine, electrolytes, and lactate measurements, there were no statistically significant differences between the groups (p>0.05). PVI-GDFM is equally safe as CFM for intraoperative fluid management during elective complete abdominal hysterectomy and bilateral salpingo-oophorectomy procedures. Pleth variability index, Fluid management, Base excess.

Implementation of a policy of universal cystoscopy at the time of hysterectomy for benign indications: A retrospective comparative study.

Lower urinary tract injury (LUTI) is a serious complication of major gynaecologic surgery. Although intra-operative cystoscopy can facilitate timely diagnosis and treatment of LUTI, the optimal approach to cystoscopy at the time of benign hysterectomy remains debatable. To assess whether implementation of a policy of universal cystoscopy at the time of benign hysterectomy was associated with a difference in intra-operative detection and rates of LUTI. Retrospective cohort study at a large regional teaching hospital where a policy of universal cystoscopy at the time of benign hysterectomy was implemented on 30 September 2019. Hysterectomies performed from 1 November 2016 to 31 March 2021 were included and categorised into the 'pre-policy' and 'post-policy' groups. Primary outcomes included the intra-operative detection and overall rates of LUTI. Secondary outcome was the policy adherence rate. Multivariate analysis was used to examine the effect of this policy on the outcomes. There were 584 hysterectomies identified, including 325 in the pre-policy group and 259 in the post-policy group. Cystoscopy was performed in 55.1% in the pre-policy group and 97.7% in the post-policy group (P < 0.01). Adjusted for age, indication and route of hysterectomy, there were no significant differences in the intra-operative cystoscopic detection of LUTI (42.9% vs 25.0%, P=0.55) or the rate of LUTI (2.2% vs 1.5%, P=0.25) after implementation of the policy. The practice of universal cystoscopy at the time of benign hysterectomy has not been associated with a significant change in the intra-operative detection and rates of LUTI at our institution.

Gynecologic Malignancy-Associated Venous Thromboembolism and Predictive Tool at Thammasat University Hospital.

Objectives:Aims were to investigate the prevalence and risk factors of venous thromboembolism (VTE) in gynecologic malignancy cases. Value of screening tool (Caprini) for prediction of VTE was also assessed. Study design:A retrospective study of gynecologic malignancy subjects who underwent major gynecological operation via exploratory laparotomy at Thammasat University Hospital, Pathum Thani, Thailand from January 2015 to December 2020. Participants were categorized into VTE and non-VTE groups. Caprini score, associated laboratory and clinical factors of both groups were evaluated. Results:A total of 392 subjects were recruited into the study. Prevalence of VTE was 7.4 (29/392) percent. VTE was diagnosed in subjects with endometrial, ovarian and cervical cancer at percentage of 7.8 (15/192), 7.9 (11/138) and 5.7 (3/53), respectively. Demographic characters of both groups were comparable. VTE group had significant more Caprini score, platelets count and platelet lymphocyte ratio (PLR) than non-VTE group. Modified Caprini score (2 multiply Caprini score plus 1 multiply PLR) was generated for better VTE prediction. Sensitivity and specificity of Caprini (≥5.5) and modified Caprini scores (≥22.8) were 72.4 vs 39.4, and 79.3 vs 52.1 percent, respectively. Conclusion:Prevalence of VTE among gynecologic malignancy cases was 7.4 percent. The modified Caprini score was an alternative VTE predictive tool. Cut-off point of modified Caprini score at equal or more than 22.8 was proposed.

The Impact of Covid-19 Pandemic on Obstetrics and Gynecology Residency Programs and Perspectives on Adaptive Ways of Training in Ethiopia

Background: The impact of Covid-19 on healthcare system and trainings has been tremendous and unpredictable. In addition to service re-organization, teaching institutions will have to devise adaptive mechanisms to cope up with the disruption in medical education and residency training. Objectives: to assess the effect of Covid-19 pandemic on obstetrics and gynecology residency program and explore residents’ &amp; program directors’ perspectives on alternative academic approaches in Ethiopia. Methods: This is a cross sectional mixed method study which was conducted at 12 institutions engaged in obstetrics and gynecology residency training in Ethiopia from May to June 2020. Quantitative data were collected from 240 residents employing an online platform (Google Forms) and focus group discussion was conducted using the ZOOM video-conferencing platform with eleven chief residents and eight program directors. Quantitative data analysis was performed using Stata 15 statistical software while thematic synthesis approach was used for the qualitative data analysis assisted by Atlas’s 7 for windows. Ethical clearance was obtained from IRB of Saint Paul’s Hospital Millennium Medical College. Results: All levels of residents from all residency sites were represented. The level of residents’ engagement in various routine clinical services vary depending on the type of service during COVID-19 pandemic period. Residents’ involvement in routine ANC, high risk clinics are “slightly” reduced while in Gynecology OPDs, the reduction was “severe”. There was no effort made to address the psychological impact of the pandemic on residents. The level of reduction in didactic and clinical teaching (rounds, case presentations, seminars, management sessions ranged from “some” to “complete interruption” for most of the residents at different years of training. Although the reduction in obstetric practical exposure (normal delivery, cesarean delivery) was “slight”, there was “sever” reduction to “complete suppression” (&gt;80%) in major gynecologic surgeries primarily affecting final year residents. Research activities are completely halted in most of the institutions. Generally, adaptive methods to sustain the residency training were implemented in very few of the institutions. Conclusions: There was significant disruption in all domains of the residency training following the report of the first case of COVID-19 in Ethiopia. The preparedness and response of the programs was very poor and there was limited effort in implementing adaptive teaching methods in almost all of the institutions.

Open abdomen technique used in complications of major gynecological oncology surgery

To evaluate the open abdomen technique (laparostomy) used in complications of major gynecological oncology surgery. We analyzed retrospectively the surgical database of all patients who had undergone major open surgery by the same gynecologic oncologist over a 5-year period. All patients who had had open abdomen procedure were identified; demographic data and indications of primary surgery, temporary abdominal closure procedure details, fascia closure and morbidity, mortality rates were evaluated. Intraabdominal infection and intraoperative massive hemorrhage were the major indications for all open abdomen cases. Mannheim Peritonitis Index was used perioperatively to determine open abdomen decision in intraabdominal infections. Vacuum Assisted Abdominal Closure system and Bogota Bag were used for temporary abdominal closure techniques. Out of the total 560 patients who had undergone major oncological surgery, 19 patients (3.3%) had open abdomen procedure due to surgical complications. Eleven patients had intraabdominal infection, six patients had hemodynamic instability due to peri and postoperative hemorrhage, two patients had gross fecal contamination during posterior pelvic exenteration surgery. The fascia was closed totally in 15 (78%), partially in 3 (15%) and could not be closed in 1 patient who had died secondary to multiorgan failure. Total morbidity and mortality rates were 26% (5/19) (two intrabdominal abscess, one pulmonary embolism, one skin necrosis, one enteroatmospheric fistula) and 5.2% (1/19) respectively. Open abdomen is a life-saving procedure when applied with correct indications and timing. Gynecological oncologic surgeries are candidates to serious complications and gynecologic oncologists dealing with such surgery should be as experienced as general surgeons in this regard.