Faculty Bibliography

OBJECTIVE: To determine factors influencing discharge patterns after laparoscopic hysterectomy for endometrial cancer and to evaluate the safety of same-day discharge during the 30-day postoperative period. METHODS: Using the American College of Surgeons' National Surgical Quality Improvement Project's database, patients who underwent hysterectomy for endometrial cancer from 2010 to 2014 were identified and categorized by their hospital length of stay. Statistical analyses were performed to assess the relationship between hospital stay and demographics, medical comorbidities, intraoperative surgical factors and postoperative outcomes. RESULTS: A total of 9020 patients had laparoscopic hysterectomies for endometrial cancer and of these, 729 patients (8.1%) were successfully discharged on the day of surgery. These patients were younger and had lower body mass indexes and fewer medical comorbidities than patients who were admitted after their procedure. The same-day discharge group underwent surgical procedures of less complexity than the hospital admission group based on shorter operative times and fewer relative value units (RVUs). There was a lower rate of surgical site infections in the same-day discharge group, and no difference in rates of other postoperative complications including hospital readmissions and reoperations. CONCLUSIONS: Rates of laparoscopic hysterectomy for endometrial cancer are gradually increasing but the rates of same-day discharge have increased at a much slower rate. Same-day discharge has been successful despite differences in preoperative demographics, medical comorbidities and intraoperative surgical complexity. Overall postoperative complication rates were equivalent despite length of hospital stay, demonstrating the safety and feasibility of same-day discharge after laparoscopic hysterectomy for endometrial cancer.

Objectives: Minimally invasive surgery is the preferred surgical method to treat women with endometrial cancer. Several single-institution reports have described the feasibility and safety of outpatient laparoscopic hysterectomies (LH) for both benign and malignant indications. The objective of this study is to identify patient and surgical factors associated with outpatient laparoscopic hysterectomies (OLH) and to compare outcomes between OLH and inpatient laparoscopic hysterectomies (ILH) in women with endometrial cancer.Methods: Data were obtained from the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database. All patients who underwent hysterectomies for endometrial cancer from 2007 to 2013 were identified by ICD-9 and CPT codes. These patients were then filtered for LH. Comparative analyses were performed and stratified by admission status to evaluate demographics, preoperative and intraoperative variables, and surgical outcomes. Statistical tests were performed with R Studio version 0.99.442.Results: LH rates have been steadily increasing. (See Table 1.) Between 2010 and 2013, 5,851 patients underwent LH for endometrial cancer; of these, 3,428 (58.6%) were ILH and 2,423 (41.4%) were OLH. OLH rates increased each year from 30.0% in 2010 to 50.0% in 2013. OLH patients were on average 61.81 years old compared with 63.03 years for ILH patients (P <.001). Medical comorbidities were not different between the 2 groups. Total operating time and anesthesia time were both significantly shorter in the OLH group: average times were 161.3 and 187.0 minutes (P <.001) and 245.2 versus 256.3 minutes (P =.002), respectively. More lymph node dissections were performed in the ILH group than the OLH group: 2,074 (60.5%) versus 1,390 (57.4%, P =.016). There were more radical hysterectomies in the ILH group (n = 803; 23.4%) compared with the OLH group (n = 315; 13.1%) (P <.001). OLHs were assigned fewer relative value units than ILHs (mean 28.5 vs 30.6, respectively, P <.001). Postoperative complications were not different between the groups.Conclusions: Younger age, fewer RVUs, shorter operating and anesthesia times were associated with successful OLH in patients with endometrial cancer. Lymph node dissection and radical surgery were associated with an increased rate of ILH. There were no differences in postoperative complications between OLH and ILH. (table present)

BACKGROUND: Widespread disparities in care have been documented in women with gynecologic cancer in the United States. This study was designed to determine whether structural barriers to optimal care were present during the preoperative period for patients with gynecologic cancer. METHODS: A retrospective review was conducted for patients undergoing surgery for a gynecologic malignancy at a public hospital or a private hospital staffed by the same team of gynecologic oncologists between July 1, 2013 and July 1, 2014. RESULTS: Two hundred fifty-seven cases were included for analysis (public hospital, 69; private hospital, 188). Patients treated at the private hospital were older (58 vs 52 years; P = .004) and had similar medical comorbidities (median Charlson comorbidity index at both hospitals, 6) but required fewer hospital visits in preparation for surgery (2 vs 4; P < .001). Public hospital patients had a longer wait time from the diagnosis of disease to surgery (63 vs 34 days; P < .001). According to a multiple linear regression model, the public hospital setting was associated with a longer interval from diagnosis to surgery with adjustments for the insurance status, age at diagnosis, cancer stage, and number of preoperative hospital visits (P < .001). CONCLUSIONS: Patients at the public hospital were subject to a greater number of preoperative visits and had to wait longer for surgery than patients at the private hospital. Attempts to reduce health care disparities should focus on improving efficiency in health care delivery systems once contact has been established. Cancer 2016;122:859-67. (c) 2016 American Cancer Society.

OBJECTIVE: We aimed to compare access to gynecologic oncology care at a private and a city hospital, both of which closed for a period of time because of Hurricane Sandy. METHODS: This was a cross-sectional study of gynecologic oncology chemotherapy, radiotherapy, and surgical patients from October 29, 2012 (the eve of the storm), to February 7, 2013 (the reopening of the city hospital). New referrals during this time were excluded. Delays in chemotherapy, radiotherapy, and surgery were compared. RESULTS: Analysis included 113 patients: 59 private patients (52.2%) and 54 city patients (47.8%). Of the private patients, 33/59 received chemotherapy (55.9%), 1/59 received radiotherapy (1.7%), and 28/59 had planned surgery (47.5%). Of the city patients, 40/54 received chemotherapy (74.1%), 7/54 received radiotherapy (12.3%), and 18/54 had planned surgery (33.3%). The mean delay in chemotherapy was 7.6 days at the private hospital and 21.7 days at the city hospital (P=0.0004). The mean delay in scheduled surgery was 14.2 days at the private hospital and 22.7 days at the city hospital (P=0.3979). The mean delay in radiotherapy was 0.0 days at the private hospital and 25.0 days at the city hospital (P=0.0046). Loss to follow-up rates were 3/59 of the private patients (5.1%) and 3/54 of the city patients (5.6%). CONCLUSIONS: Gynecologic oncology care was maintained during a natural disaster despite temporary closure and relocation of services. Disparity in care was in access to chemotherapy. (Disaster Med Public Health Preparedness. 2015;0:1-4).

Objectives: Widespread disparities in care have been documented in women with gynecologic cancer in the United States. Prior studies have focused on inequality in access and quality of care. We sought to determine if structural barriers to optimal care were present during the preoperative period for gynecologic cancer patients. Methods: We performed a retrospective review of patients undergoing surgery for a gynecologic malignancy at a public and private hospital staffed by the same gynecologic oncology team between 7/ 1/13 and 7/1/14. Statistical analyses included chi square, Student's ttest, Pearson correlation, and multivariable linear regression. Results: A total of 372 cases were identified, of which 257 were included for analysis (public 69, private 188). Patients treated at the private hospital were older (58 vs. 52 years, P= 0.003) and more likely to have medical comorbidities (71% vs. 46%, P < 0.001) but required fewer median hospital appointments in preparation for surgery (2 vs. 4, P < 0.001). Patients treated at the public hospital had a longer time interval from diagnosis to surgery (65 vs. 34 days, P < 0.001) and from surgical booking appointment to surgery (26 vs. 19 days, P =0.049). The number of contacts with the hospital system during the preoperative period was correlated with interval from diagnosis to surgery (Pearson correlation 0.324, P < 0.001) and surgical booking to surgery (Pearson correlation 0.312, P < 0.001). On a linear regression analysis model that included age, hospital setting, cancer type, disease stage, medical comorbidities and number of hospital contacts, both the public hospital setting (P =0.011) and hospital contact number (P < 0.001) were associated with a longer interval from diagnosis to surgery. Conclusions: Despite being treated by the same team of gynecologic oncologists, patients at a public hospital, who were younger and had fewer medical comorbidities, were subject to a greater number of preoperative visits and less coordination of care than patients at a private hospital. Furthermore, patients at the public hospital had to wait longer from time of diagnosis to surgery and surgical booking appointment to surgery. Attempts to reduce health care disparities should focus not just on access and quality but also on improving efficiency in health care delivery systems once contact has been established

OBJECTIVE: We sought to compare robotic versus laparoscopic surgery in regards to patient reported post-operative pain and quality of life. STUDY DESIGN: This was a prospective study of patients who presented for treatment of a new gynecologic disease requiring minimally invasive surgical intervention. All subjects were asked to take the validated Brief Pain Inventory-Short Form (BPI-SF) at 3 time points to assess pain and its effect on quality of life. Statistical analyses were performed using Pearson x2 and Student's t test. RESULTS: One hundred eleven were included in the analysis of which 56 patients underwent robotic assisted surgery and 55 patients underwent laparoscopic surgery. There was no difference in post-operative pain between conventional laparoscopy and robotic assisted surgery for gynecologic procedures. There was a statistically significant difference found at the delayed postoperative period when evaluating interference of sleep, favoring laparoscopy (ROB 2.0 v LSC 1.0; p 0.03). There were no differences found between the robotic and laparoscopic groups of patients receiving narcotics (56 vs 53, p=0.24, respectively), route of administration of narcotics (47 vs 45, p=1.0, respectively), or administration of non-steroidal anti-inflammatory medications (27 vs 21, P=0.33, respectively). CONCLUSIONS: Our results demonstrate no difference in post-operative pain between conventional laparoscopy and robotic assisted surgery for gynecologic procedures. Furthermore, pain did not appear to interfere consistently with any daily activity of living. Interference of sleep needs to be further evaluated after controlling for BSO.

Objective: Risk-reducing BSO (RRBSO), or prophylactic removal of the adnexae in women at increased genetic risk of ovarian cancer, diminishes ovarian cancer risk. While many general gynecologists (GG) perform these procedures, some argue that they should be performed exclusively by gynecologic oncologists (GO). Crucial aspects of the procedure include attention to removing all adnexal tissue, systematic methods and processing to detect occult disease, and communication between surgeon and pathologist. After compiling a "best practices" protocol for performing RRBSO, we sought to identify how often these practices were followed and whether surgeons' training affected implementation. Methods: All cases of RRBSO from 2006 to 2010 at a single institution were identified.We abstracted data from the medical record, including type of surgeon and year of procedure. We reviewed operative reports to determine if pelvic washings were obtained; whether the upper abdomen, and peritoneal surfaces were inspected; and whether a retroperitoneal approach was used to skeletonize the infundibulopelvic (IP) ligament and maximize length of this pedicle. The pathology report was used to determine if the applicable preoperative diagnosis was noted and whether the entirety of the fallopian tubes and ovaries was sectioned or if only representative sections were reviewed. Fisher's exact test and chi-square were used as appropriate to compare differences between groups (InStat, LaJolla, CA). Results: Among 290 RRBSOs, 26 were performed by GGs and 264 by GOs. When performed by GOs, the ovaries and fallopian tubes were more likely to be completely sectioned compared with GG cases: 231/264 (88%) vs. 17/26 (65%) (P =0.003). GOs were more likely to perform pelvic washings 228/264 (86%) when compared to GGs 13/ 26 (50%) (P < 0.0001). GOs were more likely to use a retroperitoneal approach to skeletonize the IP ligaments 172/264 (65%) when compared to GGs 6/26 (23%) (P < 0.0001). GOs were more likely to include a description of t!

Objective: Data regarding conservative treatment of endometrial neoplasia (EN) consist of case series and nonstandardized treatments. Prospective trial design for this regimen has been fraught with incongruity. We sought to design and implement a protocol for the conservative management of EN using a consistent treatment regimen, assessment of response, and endpoints. Methods: Women with atypical endometrial hyperplasia (AEH) or grade 1 and 2 endometrioid endometrial carcinoma (EC) with gynecologic pathologist- confirmed diagnoses, no evidence of myometrial invasion or extrauterine disease on imaging, and no contraindication to megestrol acetatewho desired conservative management of EN were enrolled on this phase 2 study. Women received 160 mg of megestrol daily. After 12 weeks of treatment, office endometrial biopsy (EMB) was performed. If EMB did not reveal negative endometrium or progression, patients could continue treatment. Those with negative EMB underwent dilation and curettage (D&C) to confirm response, and endpointwas described as pathologic complete response (pCR) on D&C. Patientswithout pCR orwith progression continued onmegestrol for an additional 12 weeks, after which they were similarly reassessed. There were no dose escalations or modifications. Treatment could continue if necessary for as long as 24 months. After pCR, patients were instructed to pursue fertility or start a lower-dose progestin-based maintenance agent. Under this 1-stage design, a sample size of 30 patients achieved 80% power to detect a difference of 0.25 between the H0 of 0.4 and the H1 of 0.65 using a 2-sided Z test. Results: Among 31 patients enrolled in the study, 30 underwent protocol-defined treatment. Ages ranged from 27 to 49 years, with a median age of 37.5 years. 42% of patients were not Caucasian. Median time on study was 210 days (range, 50-768 days). To date, 13/30 (43%) experienced pCR, 3/30 (10%) a partial response, 5/30 (17%) an unconfirmed complete response, 7/30 (23%) stable disease with 3 sti!