Major Gynaecological Surgery Research Articles

Enhanced Recovery Implementation in Major Gynecologic Surgeries: Effect of Care Standardization.

To examine implementing an enhanced recovery after surgery (ERAS) protocol for women undergoing major gynecologic surgery at an academic institution and compare surgical outcomes before and after implementation. Two ERAS protocols were developed: a full pathway using regional anesthesia for open procedures and a light pathway without regional anesthesia for vaginal and minimally invasive procedures. Enhanced recovery after surgery pathways included extensive preoperative counseling, carbohydrate loading and oral fluids before surgery, multimodal analgesia with avoidance of intravenous opioids, intraoperative goal-directed fluid resuscitation, and immediate postoperative feeding and ambulation. A before-and-after study design was used to compare clinical outcomes, costs, and patient satisfaction. Complications and risk-adjusted length of stay were drawn from the American College of Surgeons' National Surgical Quality Improvement Program database. On the ERAS full protocol, 136 patients were compared with 211 historical controls and the median length of stay was reduced (2.0 compared with 3.0 days; P=.007) despite an increase in National Surgical Quality Improvement Program-predicted length of stay (2.5 compared with 2.0 days; P=.009). Reductions were seen in median intraoperative morphine equivalents (0.3 compared with 12.7 mg; P<.001), intraoperative (285 compared with 1,250 mL; P<.001) and total intravenous fluids (-917.5 compared with 1,410 mL; P<.001), immediate postoperative pain scores (3.7 compared with 5.0; P<.001), and total complications (21.3% compared with 40.2%; P=.004). On the ERAS light protocol, 249 patients were compared with 324 historical controls and demonstrated decreased intraoperative and postoperative morphine equivalents (0.0 compared with 13.0 mg; P<.001 and 15.0 compared with 23.6 mg; P<.001) and decreased intraoperative and overall net intravenous fluids (P<.001). Patient satisfaction scores showed a marked and significant improvement on focus questions regarding pain control, nurses keeping patients informed, and staff teamwork; 30-day total hospital costs were significantly decreased in both ERAS groups. Implementation of ERAS protocols in gynecologic surgery was associated with a substantial decrease in intravenous fluids and morphine administration coupled with reduction in length of stay for open procedures combined with improved patient satisfaction and decreased hospital costs.

Indirect Calorimetry in Mechanically Ventilated Patients: A Prospective, Randomized, Clinical Validation of 2 Devices Against a Gold Standard.

The 2 currently available indirect calorimeters, CCM Express Indirect Calorimeter (MedGraphics, St Paul, MN) and Quark RMR ICU Indirect Calorimeter (COSMED, Rome, Italy), have not been validated against a gold standard in mechanically ventilated patients. Our aim was to do so using a gold-standard, modified Tissot bell-spirometer method in mechanically ventilated patients who were hemodynamically, respiratory, and metabolically stable. We studied 30 patients undergoing general anesthesia and major gynecological surgery. We measured oxygen consumption ([Formula: see text]O2) and resting energy expenditure (REE) in a randomized, sequential, crossover design with double determination of each device. Compared with the modified Tissot bell-spirometer, the CCM Express Indirect Calorimeter demonstrated a mean Δ-REE of +361 kcal/d, corresponding to a 31% overestimation of energy requirements. Bland-Altman analysis for REE showed a mean (SD) bias of 384 (124) with limits of agreement 142-627 kcal/d. QUARK RMR ICU demonstrated a mean Δ-REE of 81 kcal/d, corresponding to a 7% overestimation of energy requirements. Bland-Altman plot analysis showed a mean (SD) bias of 77 (167) with limits of agreement -249 to 404 kcal/d. The QUARK RMR ICU Indirect Calorimeter compared better with the gold standard for values of [Formula: see text]O2 and REE than did the CCM Express Indirect Calorimeter in mechanically ventilated patients who were circulatory and respiratory stable. Both indirect calorimeters had low precision.

Developing 'subject matter experts': an improvement methodology programme for acute postoperative pain with patients post major surgery.

To determine the effectiveness of an improvement methodology initiative, directed at refining the quality of acute pain management of patients in the first 24hours post major surgery using the Revised American Pain Society Patient Outcome Questionnaire, pre- and post development of a 'subject matter experts' acute pain programme. Accurately measuring effectiveness of acute pain management post major surgery is intertwined with measuring overall patient satisfaction. A critical element of quality evaluation is obtaining direct feedback from patients about the here-and-now pain experiences post major surgery. A prospective cross-sectional, observational study was conducted in a large university hospital in Ireland. The questionnaire was completed with patients within 24hours post major surgery, i.e., cardiothoracic, breast, gynaecological, gastrointestinal and urology surgery. The nurse participants were selected based on their commitment to play a key role in acute pain management. The study consisted of: a pre programme phase (n=100 patients), an intervention phase - 'subject matter experts' acute pain programme (n=24 nurses) and a postprogramme phase (n=100 patients). Over a quarter of patients were in severe pain for long periods in the first 24hours post major surgery. These findings were linked not only to ineffective analgesia from some pain drug therapies but also to contradictory messages from nurses. Over half of the patients' pre- and postintervention reported satisfaction with acute pain management, whereas the remainder were dissatisfied and some sought answers to their suboptimum pain status. The 'subject matter experts' had a noteworthy impact on the patients' pain beliefs. The findings revealed that a 'subject matter experts' acute pain programme can have a positive impact on pain management in the immediate phase post major surgery. The role making of 'subject matter experts' in acute pain is a tactical approach towards achieving optimum patient pain control in the immediate phase post major surgery.

Electronic patient-reported outcomes from home in patients recovering from major gynecologic cancer surgery: A prospective study measuring symptoms and health-related quality of life

Objectives: A pilot study suggested that the use of a web-based system to capture patient-reported outcomes (PROs) is feasible and highly accepted by patients in the acute postoperative period. The objective of this study was to further demonstrate its feasibility, measure patient assessments of its usefulness, and clinician perceptions of its value. Methods: This is a prospective cohort study of patients scheduled for laparotomy for presumed gynecologic malignancy. Patients completed a web-based Symptom Tracking and Reporting (“STAR”) questionnaire preoperatively and weekly during a 6-week postoperative period. The survey consisted of the patient adaptation of the National Cancer Institute’s CTCAE 3.0 and EORTC QLQ-C30 3.0. Email alerts were sent to clinicians when concerning patient responses were entered. The patient and the clinician assessments of STAR’s usefulness were measured via an exit survey. Results: The study enrolled 120 patients. Of these, 69 patients (57.5%) completed at least 4 of 7 total sessions. The CTC generated 84 alerts, which resulted in 28 contacts and 2 ED referrals. One hundred and twelve patient-reported symptoms generated an alert; the most common were poor performance status (15%), nausea (14%), and fatigue (12%). Fifty-one patients (42.5%) completed the exit satisfaction survey; 86% found STAR easy to use and 73% found it useful; 63% reported that STAR improved the ability to remember symptoms at office visits; 57% reported improved discussions with the provider; 43% reported overall improved quality of care; 63% felt more in control of their care by using the STAR system; and 71% would recommend it to other patients and 61% would like to continue use. Most clinicians did not find STAR helpful. Seventy-five percent did not find the self-assessments of pain and quality of life accurate. All clinicians surveyed reported that the STAR system increased their workload. Conclusions: Application of an electronic program for PROs in those recovering from major gynecologic cancer surgery is feasible and acceptable for most patients with a computer and home internet access. Poor performance status, nausea, and fatigue were the most common distressing symptoms reported. The majority of patients reported a positive experience with the system and would recommend its use. The program helped many to feel more empowered in their postoperative recovery. Clinicians reported a less positive experience, possibly associated with the increased work.

Using Bundled Interventions to Reduce Surgical Site Infection After Major Gynecologic Cancer Surgery.

To investigate whether implementing a bundle, defined as a set of evidence-based practices performed collectively, can reduce 30-day surgical site infections. Baseline surgical site infection rates were determined retrospectively for cases of open uterine cancer, ovarian cancer without bowel resection, and ovarian cancer with bowel resection between January 1, 2010, and December 31, 2012, at an academic center. A perioperative bundle was prospectively implemented during the intervention period (August 1, 2013, to September 30, 2014). Prior established elements were: patient education, 4% chlorhexidine gluconate shower before surgery, antibiotic administration, 2% chlorhexidine gluconate and 70% isopropyl alcohol coverage of incisional area, and cefazolin redosing 3-4 hours after incision. New elements initiated were: sterile closing tray and staff glove change for fascia and skin closure, dressing removal at 24-48 hours, dismissal with 4% chlorhexidine gluconate, and follow-up nursing phone call. Surgical site infection rates were examined using control charts, compared between periods using χ or Fisher exact test, and validated against the American College of Surgeons National Surgical Quality Improvement Program decile ranking. The overall 30-day surgical site infection rate was 38 of 635 (6.0%) among all cases in the preintervention period, with 11 superficial (1.7%), two deep (0.3%), and 25 organ or space infections (3.9%). In the intervention period, the overall rate was 2 of 190 (1.1%), with two organ or space infections (1.1%). Overall, the relative risk reduction in surgical site infection was 82.4% (P=.01). The surgical site infection relative risk reduction was 77.6% among ovarian cancer with bowel resection, 79.3% among ovarian cancer without bowel resection, and 100% among uterine cancer. The American College of Surgeons National Surgical Quality Improvement Program decile ranking improved from the 10th decile to first decile; risk-adjusted odds ratio for surgical site infection decreased from 1.6 (95% confidence interval 1.0-2.6) to 0.6 (0.3-1.1). Implementation of an evidence-based surgical site infection reduction bundle was associated with substantial reductions in surgical site infection in high-risk cancer procedures.

Comparative study between vaginal and abdominal hysterectomy in non-descent cases

&lt;p class="abstract"&gt;&lt;strong&gt;&lt;span lang="EN-US"&gt;Background:&lt;/span&gt;&lt;/strong&gt;&lt;span lang="EN-US"&gt; Hysterectomy is the major gynaecological surgery performed by gynaecologist all over the world. Various approaches have been tried by gynaecologist all over the world including abdominal, vaginal, laparoscopic, notes and robotic hysterectomy. Vaginal approach greatly reduces complications, decreases hospital stay, lowers hospital charges, post-operative discomfort and cosmetically better compared to abdominal and laparoscopic approaches. Vaginal hysterectomy in large sized uterus can be facilitated by bisection, myomectomy, debulking, coring and clamp less approach. The aim and objective of the study was to compare outcome of NDVH with outcome of TAH in terms of post-operative morbidity and duration of hospital stay.&lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;&lt;span lang="EN-US"&gt;Methods:&lt;/span&gt;&lt;/strong&gt;A total of 100 cases were selected with enlarged uterus of which 50 underwent NDVH and rest 50 underwent TAH. All patients were evaluated for operative time, intra-operative and post-operative complications and duration of hospital stay. Data were recorded and processed and standard statistical software were used.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;&lt;span lang="EN-US"&gt;Results:&lt;/span&gt;&lt;/strong&gt;&lt;span lang="EN-US"&gt; Patients undergoing NDVH had an average operating time of 48.68 mins whereas for those undergoing TAH was 92.52 mins (‘p’- value &amp;lt;0.001). Intra-operative complications were noted in 2% of patients undergoing NDVH whereas in 20% of patients undergoing TAH (‘p’- value 0.016). Post-operative complications were noted in 34% of patients undergoing NDVH v/s 70% in TAH (‘p’- value &amp;lt;0.001). Patients undergoing NDVH had a mean hospital stay of 5.96 days whereas 9.10 days in those undergoing TAH (‘p’- value &amp;lt;0.001).&lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;&lt;span lang="EN-US"&gt;Conclusions:&lt;/span&gt;&lt;/strong&gt;NDVH is associated with decreased operative time, post-operative morbidity, early ambulation and early discharge from hospital compared to TAH.&lt;/p&gt;

Readmissions after major gynecologic oncology surgery

ObjectivesTo examine the underlying indications, timing, and risk factors associated with unplanned hospital readmissions after major surgery for a gynecologic malignancy. MethodsThis is a retrospective database cohort study utilizing the National Surgical Quality Improvement Program database (NSQIP). The association between risk factors with respect to 30-day unplanned readmission was modeled using logistic regression. Timing of readmission and the primary reason of readmission was abstracted from the database. ResultsOverall, the unplanned readmission rate was 6.5% (832/12,804). On multivariate analysis, operative time≥3h (OR 1.39, p<0.001), open abdominal surgery (OR 2.2, p<0.001), any complication prior to discharge (OR 1.6, p<0.001), two or more additional surgical procedures (OR 1.34, p=0.003), or cervical cancer as the site of primary disease (OR 1.30, p=0.05) were noted to be independent predictors of readmission. To provide a convenient calculation of overall probability of readmission, we developed a nomogram of factors significantly predicting readmission. Overall, infections were a cause of 45% of the readmissions. Surgical Site Infections were the most common reason, accounting for 29.2% of all readmissions. A majority of the readmissions (approximately 75%) were within two weeks of discharge from the hospital. ConclusionsEfforts to reduce readmission rates should focus on identifying patients at a high risk of readmission and reducing surgical site infections. Additionally, prospective evaluation of interventions targeted at reducing readmissions should focus on the first two weeks after discharge from the hospital.

Outcome of Non-Descent Vaginal Hysterectomy at a Single Centre in Sri Lanka: an Observational Study

Introduction: Hysterectomy is the commonest major gynaecological surgery performed worldwide. Though many routes of hysterectomy are described, open abdominal approach remains the commonest route to date for indications other than genital prolapse. There is evidence of advantages of non-descent vaginal hysterectomy (NDVH) over abdominal hysterectomy in such indications. However, the acceptance rate for vaginal approach by the gynaecologists remains low. We describe the outcome data of a series of non-descent vaginal hysterectomies performed in a single centre in Sri Lanka. Objectives: To describe the post-operative outcome and complications of NDVH for benign indications of uteri less than 14 weeks size. Method: An observational study was undertaken at the ward 14 of The De Soysa Maternity Hospital, Colombo over a period of one year from May 2007 to April 2008 among women who underwent NDVH for benign conditions. Those with co-existing genital prolapse requiring surgical correction, uteri larger than 14 weeks, a history of previous abdominal surgery and medical co-morbidities were excluded from the study. Results: The study included 53 patients who underwent NDVH. The majority had a normal sized uterus 39 (73.6%). There was a statistically significant improvement in post-operative urinary index compared to pre-operative urinary index [Kruskal-Wallis test-6.155, degrees of freedom = 2, p Conclusions: The outcome and complication rates of non-descent vaginal hysterectomy this series were comparable with evidence from literature. Therefore, we conclude that NDVH is a feasible option for benign gynaecological conditions with a uterus less than 14 weeks in size in the current gynaecological practice of Sri Lanka. Sri Lanka Journal of Obstetrics and Gynaecology Vol.37(3) 2015: 42-46

The use of pupillometry as monitoring of intraoperative analgesia in the consumption of analgesics during the first 12 hours after surgery

IntroductionIntraoperative evaluation of analgesia remains today often based on heart rate and arterial pressure fluctuations. None of these parameters are specific. Incorrect handling during this process may increase surgical morbi-mortality of the patients and their acute postoperative pain. The aim of this study was to evaluate the impact of intraoperative analgesia controlled by pupillometry on postoperative analgesic consumption and the pain intensity in the first 12h in the hospital room, after major gynaecological surgery. Patients and methodsA prospective, cohort study with allocation of groups sequentially according to the programming of the operating room was designed. ASA I–III patients scheduled for elective surgery of abdominal hysterectomy by laparotomy or laparoscopy through intravenous general anaesthesia were included. Patients were divided into 2 groups: pupillometry group (P-1), in which intraoperative analgesia was guided by pupillometry, and haemodynamic group (H-2), according to values of blood pressure and heart rate. In the hospitalisation room, the values of visual analogue scale (VAS) were routinely registered with 3 courts for the study: 3, 8 and 12h of the postoperative period. Postoperative analgesia was standardised as follows: NSAIDs was administered if VAS was ≥3 or if the patient expressly requested an analgesic. After this, the efficacy of treatment was assessed. If the patient had pain, the next scheduled drug was given up to an VAS<3. Data for total analgesic consumption administered in the hospital room, VAS and adverse effects were collected within 12h postoperatively. ResultsA total of 59 patients, 30 group P-1 and 29 group H-2, were included. Group P-1 experienced less pain than group H-2, with statistical significance in each phase (VAS 3h, VAS 8h and VAS 12h). These data are consistent with the consumption of analgesics for patients. There was a statistically significant reduction (p<0.001) in the group P-1 (1.80 [DE 0.99]; medium 2, 95% confidence interval 1.43–2.17) compared with group H-2 (5.66 [1.58]; medium 6, 95% confidence interval 5.05–6.26). ConclusionsMonitoring of the intraoperative analgesia by pupillometry was able to reduce the intensity of the acute postoperative pain and analgesic consumption in the first 12h in the hospital room after major gynaecological surgery.

Comparison of the respective effects of paracetamol, pregabalin, and their combination in the treatment of postdural puncture headache following major gynecological surgery

Background and objective Postdural puncture headache (PDPH) is a very distressing symptom after spinal anesthesia. It usually resolves spontaneously but may extend the length of hospital stay. Although there are different measures to reduce the incidence, most of the times, none of them are effective. Paracetamol is commonly used for the treatment of PDPH. Pregabalin is recently being used for PDPH with effective results. In this study, our aim was to compare the respective effects of paracetamol, pregabalin, and their combination in the treatment of PDPH. Patients and methods In total, 150 patients who had undergone major gynecological surgery under spinal anesthesia and subsequently developed PDPH (diagnosed by postdural components of the pain) were randomly allocated by using computer-generated random numbers placed in sealed opaque envelopes. The patients were allocated into three equal groups ( n = 50, each group) to receive orally either a single dose of 150 mg pregabalin (group 1) or 1000 mg of paracetamol (group 2) or a combined dose of paracetamol 1000 mg plus pregabalin 150 mg (group 3). All the patients received the same drug that they had originally received, if required, and were then followed up for 4 days. A patient's headache was scored using the visual analogue scale. Results Earlier relief from PDPH and favorable adverse event profile (overall and central nervous system-related) were found in for the pregabalin–paracetamol combination compared with either of the drugs being used alone ( P Conclusion It was concluded that the pregabalin–paracetamol combination is a better option for the treatment of PDPH compared with both of the drugs when used alone.

Electronic patient-reported outcomes from home in patients recovering from major gynecologic cancer surgery: A prospective study measuring symptoms and health-related quality of life

Electronic patient-reported outcomes from home in patients recovering from major gynecologic cancer surgery: A prospective study measuring symptoms and health-related quality of life

Genital prolapse: A 5-year review at Federal Medical Centre Umuahia, Southeastern Nigeria.

Background:Genital prolapse is an important cause of morbidity among postmenopausal and multiparous women especially in our environment where a high premium is placed on large family size. This study was done to determine the prevalence, risk factors, clinical presentation, and management options of genital prolapse.Patients and Methods:Data of those diagnosed with genital prolapse were retrieved from records in the clinic, wards, theater, and from patients' folders in the medical records department.Statistical Analysis Used:Data were analyzed using Statistical Package for Social Sciences version 20 with P < 0.05.Results:Genital prolapse accounted for 0.8% of gynecological clinic attendances and 5.2% of major gynecological operations. The mean age of patients was 56.7 ± 15.5 years. Farmers constituted 60.7% of the patients while 72.1% and 70.5% were postmenopausal and grandmultiparous women, respectively. The sensation of something coming down the vagina was the most common symptom noted in 98.4% of the patients. Most (23.0%) of the patients had unsupervised delivery at home. Uterovaginal prolapse was the most common (70.5%) type of genital prolapse, and third-degree uterovaginal prolapse was its most frequent presentation. Majority of the patients (44.4%) were managed expectantly while the most common surgery performed was vaginal hysterectomy with pelvic floor repair (33.3%).Conclusion:Widespread availability of antenatal services especially in the rural communities and limitation on family size can significantly reduce the burden of this disease.

An audit of uterovaginal prolapse in Ogbomoso, south-west Nigeria

Objective: Uterovaginal prolapse (UVP) as a gynaecological problem is very common especially in multipara. This condition is important to gynaecologists practicing in Sub-Saharan Africa because of its strong link with multiparity, poor conduct of labour, and most importantly, its role as a cause of chronic morbidity in many post-menopausal women necessitating major gynaecological surgeries. Methods: A retrospective study of utero-vaginal prolapse to determine the prevalence, presentation , management patterns and complications of UVP at the Bowen University Teaching Hospital , Ogbomosho, Oyo State, Nigeria between January 1, 2010 and December 31, 2014. Relevant data were obtained from the case notes, which included age, parity, presenting symptoms, number of living children, types of delivery, types of surgical management and associated operative morbidity and mortality. The data were presented as simple percentages. Results: The prevalence of uterovaginal prolapse was 5.4%. The mean age at presentation was 51.4± 3.3 years. The mean parity was 4.2± 1.6. Fifty-six (90.3%) of them were at least 40 years old . Majority of the patients( 80.6%) were grand-multiparous. The commonest symptom was 'something coming down the vagina' in 96% of the study subjects. Difficult labour was found to be the most common associated factor in 47 (76.2%) of the patients Second degree prolapse was the commonest type of presentation (74.2%). The most common form of treatment offered was vaginal hysterectomy with pelvic floor repair, 46 (74.2%) of the patients. Twenty -four (38.7%) patients had vaginal pessaries inserted for various degrees of UVP. Conclusion: Uterovaginal prolapse is a common gynaecological condition of the parous and elderly postmenopausal women associated with a decreased body image and quality of life. Supervised hospital deliveries and limiting the family size by efficient contraception deserve priority attention to prevent this social malady. Keywords: Difficult labour, uterovaginal prolapse, hysterectomy, multiparity

A Cross-sectional Survey of Womens Provider Gender Preferences for Gynecology and Obstetrics Care at King Abdulaziz University Hospital

Objective: This study investigated women’s gender preferences for their obstetrician-gynecologist. Methods: A cross-sectional survey was conducted of participants (aged >14 years) visiting the obstetrics and gynecology clinics of King Abdulaziz University Hospital, Jeddah in March 2015. The main outcome measures included respondents’ gender preferences regarding their obstetrician-gynecologists and their ratings of the quality of care provided by male and female obstetrician-gynecologists. Results: Of the 500 women invited, 418 accepted and participated in this survey (response rate, 83.6%). Approximately 52.6% of the respondents reported selecting their physicians. Most respondents preferred a female provider for pelvic examinations (77.1%), for new-born care (64.5%), for having primary health screening (61.2%), and for major gynecological surgery (47.0%). The most common factors that affected a woman’s decision when choosing a physician were comfort with a female practitioner (20.2%), husband's preference for a female doctor (11.7%), and the physician's knowledge (11.7%). The most important physician attribute that highly impacts women’s decisions is the experience of the physician (54.5%). Across all income levels, women were likely to consult a female obstetrician/gynecologist more often and for longer periods (p=0.010). Conclusion: Women visiting the gynecology and obstetrics clinics of King Abdulaziz University Hospital prefer a female gynecologist-obstetrician.

Early Versus Delayed Postoperative Feeding After Major Gynaecological Surgery and its Effects on Clinical Outcomes, Patient Satisfaction, and Length of Stay: A Randomized Controlled Trial.

To compare early versus delayed postoperative feeding in women undergoing major gynaecological surgery with regard to clinical outcomes, duration of postoperative stay, and patient satisfaction. We conducted a parallel-randomized controlled trial at a tertiary care centre in Montreal, Quebec, between June 2000 and July 2001. Patients undergoing major gynaecological surgery were randomized following a 1:1 allocation ratio to receive either early postoperative feeding in which oral clear fluids were begun up to six hours after surgery followed by solid foods as tolerated, or delayed postoperative feeding, in which clear fluids were begun on the first postoperative day and solid foods on the second or third day as tolerated. The primary outcomes analyzed were duration of postoperative stay and patient satisfaction. Secondary outcomes included mean time to appetite, passage of flatus, and bowel movement, as well as the presence of symptoms of paralytic ileus. A total of 119 patients were randomized; 61 patients were assigned to the early feeding group and 58 to the delayed feeding group. Demographic characteristics, including age, weight, smoking status, and prior surgical history were comparable between both groups. There was no difference in length of postoperative stay between the two groups (86.4 ± 21.0 hours in the early feeding group vs. 85.6 ± 26.2 hours in the delayed feeding group; P > 0.05). No significant difference was noted in patient satisfaction (P > 0.05). No difference was found in the frequency of postoperative ileus, mean time to appetite, passage of flatus, or first bowel movement. The introduction of early postoperative feeding appears to be safe and well tolerated by patients undergoing major gynaecological surgery. The duration of postoperative stay, patient satisfaction, and gastrointestinal symptoms are comparable between patients undergoing early or delayed postoperative feeding.

Measurement and Validation of Frailty as a Predictor of Outcomes in Women Undergoing Major Gynecological Surgery

Measurement and Validation of Frailty as a Predictor of Outcomes in Women Undergoing Major Gynecological Surgery

Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations — Part I

Guidelines for pre- and intra-operative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations — Part I

Modified Frailty Index (mFI) in major gynaecological surgery: does it predict outcome?

Frailty, commonly associated with older adults, is identified by decreased reserves in multiple organ systems. Frailty has been associated with increased risk of cardiovascular disease, hypertension, cancer and death, even after adjusting for chronic conditions and disability. In the infirm, there is homeostenosis; a decreased ability to maintain homeostasis in times of acute stress. Surgery is a form of ‘acute stress’, and frailty has been associated with higher complication rates and prolonged recovery. The accumulating deficits model was applied to the National Surgical Quality Improvement Program (NSQIP) Participant Use File (2005–09) for inpatient surgical patients, and it was demonstrated that frailty affects postoperative morbidity and mortality across all surgical specialties. Frailty may also affect a patient's ability to recover from a complication, once it has occurred (Velanovich et al. J Surg Res 2013;183:104–10). Moreover, when 25 698 women with endometrial cancer (1998–2007) were evaluated from the Nationwide Inpatient Sample in the USA, the morbidity that was associated with surgery was significantly higher in women who were >80 years old, even after adjusting for medical co-morbidities (Wright et al. Am J Obstet Gynecol 2011;205:66. e1–8). More recently, in 6551 women with gynaecological cancer (2008–11), from NSQIP, the modified frailty index (mFI) was predictive of the need for critical care support and 30-day mortality after surgery. Two preoperative factors, namely albumin and mFI, allowed for greater precision in identifying women who were at higher risk for requiring transfer to an intensive care unit (>10% risk) (Uppal et al. Gynecol Oncol 2015;137:98–101). In this study by Wright et al., the authors have presented a retrospective cohort to determine the association between mFI and morbidity and mortality in women who underwent hysterectomies in US hospitals that were participating in the NSQIP (2008–12). A combined model with age, ASA class (American Society of Anesthesiologists physical status classification system; a six-category physical status classification system for assessing the fitness of cases before surgery), functional status and mFI was evaluated and was found to have a better predictive value; however, age and ASA were shown to be of higher predictive ability than mFI. In the population studied, 20% of participants were older than 60 years, and 14% had gynaecological cancers (only 1% had metastatic cancer). In addition, 99% had independent functional status; surgical complexity was not used as a prognostic factor and elective and emergency procedures were not evaluated separately. It is therefore not clear whether mFI could be useful in prospective studies for higher-severity disease or increased complexity of the surgical procedure, especially in gynaecological cancer surgery. Modified frailty index may add to the overall risk assessment for major gynaecological surgery; however, it is still unclear whether the addition of mFI would allow modification of a ‘pre-frail’ status before surgery or whether mFI would be useful as a tool for informed decision-making for an individual patient. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

A Comparison of Patient Controlled Epidural Analgesia With Intravenous Patient Controlled Analgesia for Postoperative Pain Management After Major Gynecologic Oncologic Surgeries: A Randomized Controlled Clinical Trial.

Background:Postoperative pain after major open gynecologic surgeries requires appropriate pain management.Objectives:This study aimed at comparing perioperative patient controlled epidural analgesia (PCEA) and patient controlled intravenous analgesia (PCA) after gynecologic oncology surgeries.Patients and Methods:In this clinical trial study, 90 patients with American society of anesthesiologists (ASA) class I or II scheduled for gynecologic oncologic surgeries were randomly allocated to two groups (45 patients each group) to receive: patient-controlled epidural analgesia with bupivacaine and fentanyl (PCEA group), or patient controlled intravenous analgesia (IV PCA group) with fentanyl, pethidine and ondansetron. Postoperative pain was assessed over 48 hours using the visual analog scale (VAS). The frequency of rescue analgesia was recorded. Occurrence of any concomitant events such as nausea, vomiting, ileus, purities, sedation and respiratory complications were recorded postoperatively.Results:There were no statistically significant differences in demographic data including; age, weight, ASA physical status, duration of surgery, intraoperative bleeding, and the amount of blood transfusion (P > 0.05), between the two studied groups. Severity of postoperative pain was not significantly different between the two groups (P > 0.05); however, after first patient mobilization, pain was significantly lower in the epidural group than the IV group (P < 0.001). There was no significant difference between the two groups regarding the incidence of complications such as nausea, vomiting, purities or ileus (P > 0.05). Nevertheless, the incidence and severity of sedation was significantly higher in the IV group (P < 0.001). Respiratory depression was higher in the IV group than the epidural group; this difference, however, was not significant (P = 0.11). In the epidural group, only 10 patients (22.2%) had mild and transient lower extremities parenthesis.Conclusions:Both intravenous and epidural analgesic techniques with combination of analgesics provide proper postoperative pain control after major gynecologic cancer surgeries without any significant complications. Regarding lower sedative and respiratory depressant effects of epidural analgesia, it seems that this method is a safer technique for postoperative pain relief in these patients.

Is Decreased Insufflation Pressure During Major Robotic-Assisted Gynecologic Surgery Associated With Decreased Recovery Time and Patient Reported Pain Score.

Is Decreased Insufflation Pressure During Major Robotic-Assisted Gynecologic Surgery Associated With Decreased Recovery Time and Patient Reported Pain Score.