The prevalence of hyperglycemia and its association with perioperative outcomes in gynecologic surgery: a retrospective cohort study.

BACKGROUND: Preoperative hyperglycemia has been associated with perioperative morbidity in general surgery patients. Additionally, preoperative hyperglycemia may indicate underlying impaired glucose metabolism. Thus, identification of preoperative hyperglycemia may provide an opportunity to mitigate both short-term surgical and long-term health risk. We aimed to study this phenomenon specifically in the gynecologic surgery population. Specifically, we aimed to evaluate the association between preoperative hyperglycemia and perioperative complications in gynecologic surgery patients and to characterize adherence to diabetes screening guidelines. METHODS: This retrospective cohort study included 913 women undergoing major gynecologic surgery on an enhanced recovery pathway from January 2018 to July 2019. The main exposure was day of surgery glucose ≥ 140 g/dL. Multivariate regression identified risk factors for hyperglycemia and composite and wound-specific complications. RESULTS: Sixty-seven (7.3%) patients were hyperglycemic. Diabetes (aOR 24.0, 95% CI 12.3-46.9, P < .001) and malignancy (aOR 2.3, 95% CI 1.2-4.5, P = .01) were associated with hyperglycemia. Hyperglycemia was not associated with increased odds of composite perioperative (aOR 1.3, 95% CI 0.7-2.4, P = 0.49) or wound-specific complications (aOR 1.1, 95% CI 0.7-1.5, P = 0.76). Of nondiabetic patients, 391/779 (50%) met the USPSTF criteria for diabetes screening; 117 (30%) had documented screening in the preceding 3 years. Of the 274 unscreened patients, 94 (34%) had day of surgery glucose levels suggestive of impaired glucose metabolism (glucose ≥ 100 g/dL). CONCLUSION: In our study cohort, the prevalence of hyperglycemia was low and was not associated with higher risk of composite or wound-specific complications. However, adherence to diabetes screening guidelines was poor. Future studies should aim to develop a preoperative blood glucose testing strategy that balances the low utility of universal glucose screening with the benefit of diagnosing impaired glucose metabolism in at-risk individuals.

Should body mass index replace age to drive the decision for endometrial sampling in premenopausal women with abnormal uterine bleeding?

OBJECTIVE: This study aimed to evaluate risk factors for endometrial intraepithelial neoplasia/malignancy in premenopausal women with abnormal uterine bleeding or oligomenorrhea. Specifically, we aimed to elucidate whether body mass index (BMI) or age confers a higher risk. STUDY DESIGN: A retrospective cohort study was performed at a large academic center examining risk factors for endometrial hyperplasia/malignancy in premenopausal women undergoing endometrial sampling. RESULTS: Of the 4170 women ages 18-51 who underwent endometrial sampling from 1987 to 2019, 77 (1.85%) were found to have endometrial intraepithelial neoplasia or malignancy. Clinical predictors of EIN/malignancy in this population included obesity (OR: 3.84, 95%, p < .001), Body mass index [(OR30 vs. 25:2.11, p < .001) and OR35 vs. 30: 1.65, p < .001], Diabetes (OR: 3.6, p-value <.001), hormonal therapy use (OR: 2.93, p < .001), personal history of colon cancer (OR: 9.90, p = .003), family history of breast cancer (OR: 2.65, p < .001), family history of colon cancer (OR: 3.81, p < .001), and family history of endometrial cancer (OR: 4.92, p = .033). Age was not significantly associated with an increased risk of disease. Adjusting for other factors, a model using BMI to predict the risk of EIN/malignancy was more discriminative than a model based on age. CONCLUSIONS: Increased BMI, may be more predictive of endometrial hyperplasia/malignancy than age in premenopausal women with abnormal uterine bleeding. Modification of evaluation guidelines in a contemporary demographic setting could be considered.

Enhanced recovery after surgery in minimally invasive gynecologic surgery surgical patients: one size fits all?

PURPOSE OF REVIEW: Enhanced recovery after surgery (ERAS) programs aim to expedite functional recovery and improve surgical outcomes without increasing complications or cost. First championed by colorectal surgeons, ERAS protocols are now widely utilized among surgical subspecialties. The present review focuses on use of ERAS pathways in minimally invasive gynecologic surgery (MIGS) and risk factors for suboptimal outcomes in this population. RECENT FINDINGS: Studies across multiple fields has shown benefit to adoption of ERAS protocols. However, lack of protocol standardization among institutions, implementation of interventions as a bundle, varied compliance, and lack of study randomization collectively obscure generalizability of findings from such studies. Emerging data in fact suggest benefits may not translate equally across all populations, cautioning against indiscriminate application of protocols to all surgeries or patients. Thus applicability of ERAS protocols to the MIGS population merits close examination. SUMMARY: ERAS protocols improve postoperative outcomes, satisfaction, and cost of care for most patients undergoing gynecologic surgery. However, modifications to typical ERAS protocols may be beneficial to certain subsets of patients including patients with chronic pelvic pain, opiate dependence, or psychiatric disorders. Identification of risk factors for admission or increased hospital stay may help guide protocol modifications for at-risk groups within the MIGS population.

Compliance and outcomes after implementation of an enhanced recovery surgical protocol in older women undergoing pelvic reconstructive surgery.

The aim of this study is to evaluate compliance and outcomes with implementation of an enhanced recovery surgical protocol in older women undergoing pelvic reconstructive surgery. This is a retrospective cohort study of women undergoing pelvic reconstructive surgery after implementation of the pathway over a 12-month period. Overall compliance was defined as a categorial variable requiring adherence to all of the selected bundle components in patients <65 years old compared to those ≥65. Intraoperative and 30-day postoperative complications were also compared and were reviewed by organ system, these were categorized using the Clavien-Dindo Classification system. There was no significant difference in overall compliance in patients <65 compared to ≥65. Factors that increased compliance in patients ≥65 include laparotomy, hysterectomy, hyperlipidaemia, time after implementation of the protocol and primary surgeon. There was an increase in compliance from 19% to 77% over the 12-month study period. Intra and postoperative complications were similar between the two groups. Enhanced recovery in older patients undergoing pelvic reconstructive surgery is feasible with similar rates of compliance and complications compared to younger patients. Compliance with the protocol increases as time after implementation of the protocol increases in all patients.