Prevention of venous thromboembolism in gynecologic oncology surgery

Gynecologic oncology patients are at a high-risk of postoperative venous thromboembolism and these events are a source of major morbidity and mortality. Given the availability of prophylaxis regimens, a structured comprehensive plan for prophylaxis is necessary to care for this population. There are many prophylaxis strategies and pharmacologic agents available to the practicing gynecologic oncologist. Current venous thromboembolism prophylaxis strategies include mechanical prophylaxis, preoperative pharmacologic prophylaxis, postoperative pharmacologic prophylaxis and extended duration pharmacologic prophylaxis that the patient continues at home after hospital discharge. In this review, we will summarize the available pharmacologic prophylaxis agents and discuss currently used prophylaxis strategies. When available, evidence from the gynecologic oncology patient population will be highlighted

The limited utility of currently available venous thromboembolism risk assessment tools in gynecological oncology patients

Use of risk assessment tools, such as the Caprini score or Rogers score, is recommended by national societies to stratify surgical patients by venous thromboembolism (VTE) risk and guide prophylaxis. However, these tools were not developed in a gynecologic oncology patient population and their utility in this population is unknown

Trainee participation and perioperative complications in benign hysterectomy: the effect of route of surgery

BACKGROUND: Intraoperative trainee involvement in hysterectomy is common. However, the effect of intraoperative trainee involvement on perioperative complications depending on surgical approach is unknown. OBJECTIVE: To estimate the effect of intraoperative trainee involvement on perioperative complication after vaginal, laparoscopic, and abdominal hysterectomy for benign disease. METHODS: Patients undergoing laparoscopic, vaginal, or abdominal hysterectomy for benign disease from 2010 to 2012 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Patients with and without trainee involvement were compared with regard to perioperative complications. Complications that occurred from the start of surgery to 30-days postoperatively were included. Perioperative complications were defined via the use of the validated Clavien-Dindo scale with ≥grade 3 complications defined as major and ≤grade 2 complications defined as minor. Major complications included myocardial infarction, pneumonia, venous thromboembolism, deep or organ space surgical-site infection, stroke, fascial dehiscence, unplanned return to the operating room, renal failure, cardiopulmonary arrest, sepsis, intubation greater than 48 hours, and death. Minor complications included urinary tract infection, blood transfusion, and superficial wound infection. To estimate the effect of trainee involvement depending on route of surgery, a stratified analysis was performed. Bivariable analysis and adjusted multivariable logistic regression were used. RESULTS: We identified 22,499 patients, of whom 42.1% had trainee participation. Surgical approaches were vaginal (22.7%), abdominal (47.1%), and laparoscopic (30.2%). The rate of major complication was 3.2%, and minor complication was 7.2%. In bivariable analysis, trainee involvement was associated with major complications in vaginal hysterectomy (3.3% vs 2.3%, P = .03), but not laparoscopic (3.0% vs 2.9%, P = .78) or abdominal hysterectomy (4.4% vs 3.6%, P = .07). Trainee involvement was also associated with minor complication in vaginal (7.3% vs 5.4%, P = .007), laparoscopic (5.9% vs 4.3%, P < .001), and abdominal hysterectomy (14.1% vs 9.2%, P < .001). In a multivariable analysis in which we adjusted for age, body mass index, medical comorbidity, American Society of Anesthesiologists score, and surgical complexity, the association between trainee involvement in vaginal hysterectomy and major complication persisted (adjusted odds ratio 1.45, 95% confidence interval 1.03-2.04); however, when operative time was added to the model, there was no longer an association between trainee involvement and major complication (adjusted odds ratio 1.26, 95% confidence interval 0.89-1.80). CONCLUSION: Surgical approach influences the relationship between trainee involvement and perioperative complication. Operative time is a key mediator of the relationship between trainee involvement and complication, and may be a modifiable risk factor

Venous Thromboembolism in Minimally Invasive Compared With Open Hysterectomy for Endometrial Cancer

OBJECTIVE: To evaluate whether minimally invasive surgery for endometrial cancer is independently associated with a decreased odds of venous thromboembolism compared with open surgery. METHODS: We performed a secondary analysis cohort study of prospectively collected quality improvement data and examined patients undergoing hysterectomy for endometrial cancer from 2008 to 2013 recorded in the National Surgical Quality Improvement Program database. Patients undergoing minimally invasive (laparoscopic or robotic) surgery were compared with those undergoing open surgery with respect to 30-day postoperative venous thromboembolism. Demographic and procedure variables were examined as potential confounders. Data regarding receipt of perioperative venous thromboembolism prophylaxis were not available. Bivariable tests and logistic regression were used for analysis. RESULTS: Of 9,948 patients who underwent hysterectomy for the treatment of endometrial cancer, 61.9% underwent minimally invasive surgery and 38.1% underwent open surgery. Patients undergoing minimally invasive surgery had a lower venous thromboembolism incidence (0.7%, n=47) than patients undergoing open surgery (2.2%, n=80) (P<.001). In a multivariate model adjusting for age, body mass index, race, operative time, Charlson comorbidity score, and surgical complexity, minimally invasive surgery remained associated with decreased odds of venous thromboembolism (adjusted odds ratio 0.36, 95% confidence interval 0.24-0.53) compared with open surgery. CONCLUSION: Minimally invasive surgery for the treatment of endometrial cancer is independently associated with decreased odds of venous thromboembolism compared with open surgery

Beam Based Alignment of Interaction Region Magnets

In conventional beam based alignment (BBA) procedures, the relative alignment of a quadrupole to a nearby beam position monitor is determined by finding a beam position in the quadrupole at which the closed orbit does not change when the quadrupole field is varied. The final focus magnets of the interaction regions (IR) of circular colliders often have some specialized properties that make it difficult to perform conventional beam based alignment procedures. At the HERA interaction points, for example, these properties are: (a) The quadrupoles are quite strong and long. Therefore a thin lens approximation is quite imprecise. (b) The effects of angular magnet offsets become significant. (c) The possibilities to steer the beam are limited as long as the alignment is not within specifications. (d) The beam orbit has design offsets and design angles with respect to the axis of the low-beta quadrupoles. (e) Often quadrupoles do not have a beam position monitor in their vicinity. Here we present a beam based alignment procedure that determines the relative offset of the closed orbit from a quadrupole center without requiring large orbit changes or monitors next to the quadrupole. Taking into account the alignment angle allows us to reduce the sensitivity to optical errors by one to two orders of magnitude. We also show how the BBA measurements of all IR quadrupoles can be used to determine the global position of the magnets. The sensitivity to errors of this method is evaluated and its applicability to HERA is shown

Enhanced Recovery Pathways in Gynecology and Gynecologic Oncology

Enhanced recovery programs (ERPs) are considered standard of care across a variety of surgical disciplines, but ERPs have not been widely adopted in gynecology

The health-related quality of life journey of gynecologic oncology surgical patients: Implications for the incorporation of patient-reported outcomes into surgical quality metrics

To report the changes in patient-reported quality of life for women undergoing gynecologic oncology surgeries

Who presents satisfied? Non-modifiable factors associated with patient satisfaction among gynecologic oncology clinic patients

To examine associations between non-modifiable patient factors and patient satisfaction (PS) among women presenting to a gynecologic oncology clinic

Laparoscopic adjustable gastric banding – should a second chance be given?

Background: Obesity is a chronic relapsing-remitting disease and a global pandemic, being associated with multiple comorbidities. Laparoscopic adjustable gastric banding (LAGB) is one of the safest surgical procedures used for the treatment of obesity, and even though its popularity has been decreasing over time, it still remains an option for a certain group of patients, producing considerable weight loss and improvement in obesity-associated comorbidities. Methods: The aim of this study was to evaluate the impact of weight loss following LAGB on obesity-associated comorbidities, and to identify factors that could predict better response to surgery, and patient sub-groups exhibiting greatest benefit. A total of 99 severely obese patients (81.2% women, mean age 44.19 ± 10.94 years, mean body mass index (BMI) 51.84 ± 8.77 kg/m2) underwent LAGB in a single institution. Results obtained 1, 2, and 5 years postoperatively were compared with the pre-operative values using SPPS software version 20. Results: A significant drop in BMI was recorded throughout the follow-up period, as well as in A1c and triglycerides, with greatest improvement seen 2 years after surgery (51.8 ± 8.7 kg/m2 vs 42.3 ± 9.2 kg/m2, p < 0.05, 55.5 ± 19.1 mmol/mol vs 45.8 ± 13.7 mmol/mol, p < 0.05, and 2.2 ± 1.7 mmol/l vs 1.5 ± 0.6 mmol/l). Better outcomes were seen in younger patients, with lower duration of diabetes before surgery, and lower pre-operative systolic blood pressure. Conclusions: Younger age, lower degree of obesity, and lower severity of comorbidities at the time of surgery can be important predictors of successful weight loss, making this group of patients the ideal candidates for LAGB

Does the Robotic Platform Reduce Morbidity Associated With Combined Radical Surgery and Adjuvant Radiation for Early Cervical Cancers?

Open radical hysterectomy followed by adjuvant radiation for cervical cancer has been associated with significant rates of morbidity. Radical hysterectomy is now often performed robotically. We sought to examine if the robotic platform decreased the morbidity associated with radical hysterectomy followed by adjuvant radiation