prised 195 patients undergoing major gynecologic surgery. As in the original trial, patients were aged 18–80 years, were expected to require in-hospital analgesic treatment for postoperative pain for at least 3 full days and analgesic treatment following discharge over a 10-day period follow- ing surgery, and were required to have an American Society of Anesthesiologists Grade I–III for preoperative health. The original clinical trial was approved by the appropri- ate institutional review boards, and all patients provided informed consent.
few reports on VTE after gynecologic surgery; Horowitz found that obesity, a long period of immobilization, extensive cancer surgery, trauma, radiotherapy, a past his- tory of VTE, severe varices, diabetes, and heart failure were risk factors of postoperative VTE . This report is com- parable with results of the present study. Our results are also comparable with the ACCP guidelines, which catego- rize patients ≥ 40 years old with extensive surgery and malignant tumors as the highest-risk group . The JSA has also reported that obesity, long-term immobilization, and malignant tumors are risk factors for perioperative PTE, especially in female patients . Of the 32 patients with postoperative PTE in the present study, 50% had endometrial cancer, which is often associated with obes- ity, hypertension, and abnormal glucose tolerance. Endometrial cancer is increasing relative to cervical cancer in Japan as well as the USA and Europe. Therefore, endometrial cancer appears to be one of the strongest risk factors for postoperative PTE among malignant gyneco- logic tumors. Thrombosis occurs due to Virchow's triad, namely 1) hypercoagulability, 2) stagnation of blood, and 3) vascular endothelial cell damage. Retroperitoneal lymph node dissection was not identified as an independ- ent risk factor for PTE according to multivariate analysis in the present study. Lymph node dissection may be closely related to the occurrence of VTE since this procedure causes vascular damage and also accumulations of lymph may compress the veins after surgery and cause stagnation of blood. As shown in Table 6, the incidence of postoper- ative PTE was increased in patients who had both pelvic and para-aortic lymph node dissection.
Abstract: Objective: This study aimed to investigate the effect of prophylactics on lower-extremity deep venous throm- bosis (LEDVT) in high-risk patients after gynecologic surgery. Method: A total of 690 patients with a high risk of deep venous thrombosis (DVT) were included. The patients were divided into four groups by envelope method. Graduated compression stockings (GCS) were used as a basic prophylactic for DVT in the control group, while advanced pro- phylactics, such as GCS + low-molecular-weight heparin (LMWH), GCS + intermittent pneumatic compression (IPC), and GCS + IPC + LMWH, were given in the other three groups, LMWH, IPC, and IPC + LMWH (IL) groups, respectively. The thrombosis indices, including blood routine test, coagulation function indicators, and thrombosis indicators, were recorded. Results: The incidence of DVT in the control, LMWH, IPC, and IL groups was 7.1% (26/366), 2.6% (9/352), 2.5% (8/322), 1.5% (5/340), respectively. The incidence of DVT in the experimental groups decreased significantly. The white blood cell (WBC) count increased significantly after surgery compared with that before sur- gery. The hemoglobin concentration, hematocrit, and mean platelet decreased in all the groups. The prothrombin time and activated partial thromboplastin time prolonged significantly and the fibrinogen level increased; however, the thrombin time dropped. The tissue-type plasminogen activator, plasminogen activator inhibitor, protein C, and protein S all decreased, while the D-dimer increased after surgery. The antithrombin III (AT-III) decreased only in the LMWH and IL groups. Conclusions: A single preventive method was not enough to avoid thrombosis in high-risk patients; however, a superimposition of preventive methods could significantly reduce the incidence of thrombosis.
Our data show that the use of liposomal bupivacaine with scheduled acetaminophen and scheduled tramadol and oxycodone as needed was associated with a dramatic reduction in the overall opioid use. Similar results have been shown with oncologic patients. 2-6 This, however, is the first study to demonstrate 53% overall reduction in opioid use when compared to control, in a population that expects to experience minimal to no pain with surgery and often demands high potency opioids. Our study is the first to have a sample with 70% and 31% obesity and morbid obesity rates, respectively. The multimodal approach was associated with a 47% reduction in opioid use in obese patients. Our protocol was associated with 54% reduction in opioid use among the morbidly obese. This protocol was associated with 44% reduction in opioid use in patients with benign disease. Our data show a reduction of 62% reduction in opioid use for those with malignancy, which is greater than the approximate 50% reported in the
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elective gynecologic operations under general anesthesia were included in the study. After induction of standard general anesthesia an appropriate size ProSeal LMA was inserted and controlled ventilation was established. Position of LMA was detected via auscultation of the lungs and epigastric area. Before the end of surgery, an arterial blood sample was withdrawn for blood gas analysis.
The PMGP, as well as the gynecological oncology ser- vice, maintains a Provincial Cancer Genetics database of all women affected by inherited cancers in the province. Women affected by LS who had undergone prophylactic gynecological surgery within the previous five years were identified through this database. We also searched for female carriers of LS who chose not to have surgery, and identified one who could participate during the re- cruitment period. Women were purposively sampled to provide a breadth of experience with surgery decisions (e.g., those who lived in rural and urban areas, of differ- ent ages, and those for whom varying amounts of time had passed since surgery). These women were con- tacted by telephone by their physician and asked to call the research team if they were interested in participat- ing. In total, 14 potential participants were approached with ten eventually completing an interview. Time con- straints during the data collection period precluded four women from participating. Consent was obtained via post before the interview, and verbal consent at the interview.
Normally, surgery causes trauma to the body, activat- ing the coagulatory and immune responses; complica- tions greatly increases the activity of these systems. These two processes have mostly been studied as func- tioning independently of each other; however, numerous researches have determined several checkpoints that affect both the hemostatic and the immune response/in- flammatory cascades. In fact, coagulation and inflamma- tion are activated by the same types of injuries, usually with a precise temporal correlation. During surgery, when tissues are damaged, macrophages are activated and various monokines are released, mainly tumor ne- crosis factor α (TNF-α), interleukin 6 (IL-6), and IL-1β , which in turn promote acute-phase protein synthe- sis in the liver [11, 12]. C-reactive protein, serum amyl- oid A, haptoglobin, hepcidin, α1-antitrypsin, α1-acid glycoprotein, and fibrinogen are the main acute-phase reactants . In case of complications, the organ dam- age is greater resulting in increased serum levels of such inflammation markers. These increases may be suffi- ciently sensitive to allow early diagnosis of the same complications.
This study investigated the perspectives of expert UroGyn surgeons. The researchers accessed participants at two presti- gious professional conferences where these experts gathered annually. They were invited to participate by a peer, either just before or during the conference, and then scheduled and consented per human subjects requirements. Participants who initially agreed and came to scheduled appointments were presented by the researcher with the Institutional Review Board-approved consent document, allowed to read it, invited to ask any questions, and given free choice to accept or decline. They were aware of who would read their deidentified responses (the research team members’ names were listed on the consent document). Those names included one coauthor who was a peer, an expert ObGyn surgeon in the professional community, and one who was a fellow in ObGyn surgery working under that peer. All 16 who came to appointments accepted, signed the consent document, and participated in the interviews. Twenty-one were invited, and 16 participated (71%).
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The significantly poor sleep only in the very last preoperative night suggests a late psychological change when the threat of surgery becomes imminent. Whether deterioration in sleep quality begins earlier in the preoper- ative period and gradually becomes more severe remain to be examined in a larger study or using more sensitive testing method such as polysomnography. However, this test has an inherent limit of the sample size, and it is not applicable to the patient’s natural environment. Further- more, it is expensive, time-consuming, and requires skilled personnel for testing and interpretation of data . Polysomnography is suitable for evaluation of patients with certain pathologies such as obstructive sleep apnea or chronic sleeping disorders. It is not the tool of choice for
closing trocar skin incision was 119.89 min (±43.441) and mean console time was 76.56 min (±32.904). The average patient body weight was 70.56 kg (±18.272; range, 41– 114) with mean body mass index (BMI) of 27.30 (±6.938). No significant difference was observed between the BMI and operative time (p=0.49). No significant intra-operative complications were registered. An ureterovaginal fistula was diagnosed on the 10th postoperative day in one of the patients (2%). Robot-assisted endoscopic gynecologic surgery is a modern and advanced method for operative treatment of benign and malignant gynecological tumors. It is appropriate for obese patients as the obesity is not related to a prolonged operative time.
Recently, laparoscopic surgery has developed into a mature minimally invasive diagnostic and therapeutic measure. Most gynecologic diseas- es can be cured with laparoscopic surgery. At the same time, this kind of therapy has several advantages, such as less surgery trauma, rapid postoperative recovery and so on . During the gynecologic laparoscopic surgeries, the main problems we faced are obstructions on the pathophysiology of patients caused by the special position and the artificial carbon diox- ide pneumoperitoneum . Because the car- bon dioxide pneumoperitoneum is able to leave a series of impacts on the respiration and circu- lation of patients, the risk of mild acidosis and hypercapnia may be increased in the surgery [7, 8]. However, if we take proper anesthesia methods which are safe, effective and have a little influence on the laparoscopic gynecologic surgeries, we will be able to decrease or even minimize the impacts on organisms and then achieve the optimal operation effect. The anes- thesia method of laparoscopic gynecologic sur- gery is controversial in clinic at present [9, 10]. And plenty of researches indicated that the laparoscopic gynecologic surgery had a high expectation for the anesthesia methods . Nowadays, general anesthesia combined with continuous epidural anesthesia, general anes- thesia and continuous epidural anesthesia are three commonly used anesthesia methods. Table 4. Comparison of satisfaction of anesthesia among the three groups
Operative laparoscopy was initially developed in the field of gynecology earlier on and the advent of laparoscopic surgery led to advances in general surgery as well. In the last few years, a number of articles have been published on the performance of surgical procedures using the robot-assisted laparoscopy. The shortcomings of conventional laparoscopy have led to the development of robotic surgical system and future of telero- botic surgery is not far away, enabling a surgeon to operate at a distance from the operating table. The complete loss of tactile sensation is often quoted as a big disadvantage of working with robotic systems. Although the first generation da Vinci robotic surgical system provides improved imaging and instrumentation, the absence of tactile feedback and the high cost of the technology remain as limitations. New generations of the robotic surgical systems have been developed, allowing visualization of preoperative imaging during the operation. Though the introduction of robotics is very recent, the potential for robotics in several specialties is significant. However, the benefit to patients must be carefully evaluated and proven before this technology can become widely accepted in the gynecologic surgery.
the lesion excision inside uterine cavity as well as the dilation of cervix will causes the pain on patients, and lead to the excitement of vagus nerve; clinically, patients are easily to show complications like induced abortion syndrome. Therefore, how to effectively ensure anodynia for patients is particularly important in the pro- cess of laparoscopic gynecologic surgery [10- 12]. If a safe and effective anesthesia method, which has little impact on the physical condi- tion of patients, could be applied in the gyneco- logic laparoscopic surgery, we can further mini- mize the surgical impact on patients and achieve an ideal optimization of surgery. Cli- nically, the arguments on anesthesia method in gynecological laparoscopic surgery never stopped [13-16]. At present, the commonly used methods are combined spinal-epidural anesthesia and intravenous combined anes- thesia; there are many studies on the effect of anesthesia in gynecological laparoscopic sur- gery, but the results are inconsistent. And a number of studies have indicated that gyneco- logical laparoscopic surgery has strict require- ments on anesthesia, mainly related with the high requirements on anesthetic plane [17, 18].
Abstract Laparoscopy is one of the most common surgical procedures in gynecologic medicine. Major complications associated with gynecologic laparoscopy are relatively rare, with up to 50% related to laparoscopic entry. Several entry techniques have been developed, all of which aim to provide a safe and easy entry to the abdominal cavity. In this article, we aim to review the available evidence on laparoscopic entry techniques in gynecologic surgery. We found no evidence that the Hasson (open) technique is superior to the Veress needle entry, the preferred method of most gynecologists all over the world. When entering the abdomen using the Veress needle, an intraperitoneal pressure <10 mmHg is a reliable predictor of correct intraperitoneal placement. Entry at Palmer’s point (left upper quadrant laparoscopy) is recommended for patients with suspected or known periumbilical adhesions, or a history or presence of umbilical hernia, or after three failed insufflation attempts at the umbilicus. Recently published trials suggest that direct trocar entry, especially when using optical trocar systems, might be superior to both the Hasson open technique and the Veress needle entry to avoid extraperitoneal insufflation and failed entry. Moreover, blood loss can be reduced and the mean entry time shortened. Laparoscopic entry techniques are still a contro- versial topic in gynecologic surgery. Many studies are
Routine pre-operative bowel preparation should not be used before minimally invasive gynecologic surgery. Its use is simi- larly discouraged before open laparotomy in gynecologic surgery/gynecologic oncology, especially within an established ERAS pathway. Surgeons who feel bowel preparation is necessary should limit its use to patients in which a colon resection is planned. In these cases the use of oral antibiotics alone should be considered or combined with mechanical bowel preparation. High quality data from the colorectal literature have shown that mechanical bowel preparation alone does not decrease post-operative morbidity and should thus be abandoned.
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The field of minimally invasive surgery and devices used keep on improving and evolving. There have been several advancements in electrosurgical devices used in laparoscopic procedures to manage endometrial cancer. The conventional monopolar and bipolar devices could cause thermal damage, so innovations have been made to address this issue. One of the most active surgical teams in performing laparoscopic radical hysterectomy has developed a pulsed bipolar system. They have reported better surgical outcomes including less complications, operation time, and blood loss. In line with these findings, Lee et al. indicated that pulsed bipolar systems could offer advantages in the management of early cervical carcinoma in patients undergoing laparoscopic radical hysterectomy and pelvic lymphadenectomy (36). Laparasonic devices including harmonic scalpel and coagulating shears have also been compared to electrosurgical devices in lymph node dissection and laparoscopic hysterectomy. Holub et al. reported these devices as more cost-effective alternatives with less thermal injury in lymph node dissection procedures (37). A randomized trial reported the superiority of a multifunctional instrument that integrates ultrasonic waves and advanced bipolar energy with simultaneous sealing and dissection capabilities. They found that these modified electrosurgical devices could save time and result in less postoperative pain to treat early stages of cervical cancer in patients undergoing laparoscopic radical hysterectomy and lymphadenectomy(38).
Endometrial cancer occurs most frequently in women over fifty, but increases in younger patients. The increased number of women who delay childbearing has made fertility preservation more important in treatment of this cancer. Endometrial cancer occurs in the uterine cavity, which contains the placenta and fetus, and this makes it difficult to preserve fertility in surgery. However, well-differentiated adenocarcinoma in younger women is of- ten hormone-dependent and is likely to be responsive to hormone therapy -. Hormone drugs used for endometrial cancer include progestogens such as medroxy progesterone acetate (MPA). Progestin therapy is used for patients with a histological diagnosis of grade 1 endometrioid adenocarcinoma and no muscle invasion or ectopic metastasis. In a systematic review of 2471 patients with advanced or recurrent endometrial cancer treated with hormone drugs in 5 randomized comparative studies and 29 phase II studies, Decruze et al. found an overall response rate to hormone therapy of 11% to 56% in previously untreated patients with grade 1 or 2 endometrial cancer and progression-free survival of 2.5 - 14 months . Metformin may decrease the risk for recurrence after MPA treatment, but this treatment is not recommended in the guidelines. Metformin is a type 2 diabetes drug that also inhibits cancer cell growth by AMP-activated protein kinase (AMPK) activation in the mammalian target of rapamycin (mTOR)/S6 kinase (S6K) pathway -. Two retrospective studies have shown improved relapse-free and overall survival in patients treated with metformin  . Further studies of treatment with these less invasive drugs may establish procedures for fertility preservation in patients with en- dometrial cancer.
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In the open-label randomized phase 3 ICON7 trial, PFS was signi ﬁ - cantly improved in patients receiving bevacizumab combined with front-line carboplatin and paclitaxel and then continued as a single agent for up to a total of 12 months compared with patients receiving the same chemotherapy alone. The hazard ratio (HR) for PFS was 0.81 (95% con ﬁ dence interval [CI], 0.70 – 0.94; P = 0.004) . No OS differ- ence was detected in the intent-to-treat (ITT) population . However, exploratory analyses suggested improved OS with bevacizumab- containing therapy in a prede ﬁ ned subgroup of patients considered to be at high risk of disease progression (International Federation of Gyne- cology and Obstetrics [FIGO] stage III with residuum N 1 cm, any FIGO stage IV, or no debulking surgery). This subgroup was prospectively
The target of medical optimization is to identify pre-existing comor- bidities and manage them before surgery. Measures to achieve medical optimization in our program are shown in Table 1. It is strongly recommended to stop tobacco and alcohol consump- tion. Smokers can enroll in a hospital pulmonology program that consists of behavioral support and nicotine replacement therapy, if needed. Pre-operative screening for anemia is evaluated through a blood test in pre-operative assessment. Pre-operative intrave- nous or oral iron is recommended if hemoglobin levels are <11 g/ dL. During pre-operative evaluation, other comorbidities such as hypertension, chronic obstructive pulmonary disease, chronic heart disease, and diabetes are managed to gain optimal control before
This is a descriptive study with retrolection collection of data held in the breast oncology Gynecological Surgery Oncology at the National Institute of Rabat during the period from 3 January 2017 to 3 April 2019. For example, some pa- tients were followed for two years while others were followed for only two months.