Narasimhulu, Deepa Maheswari

Objective: Using a triage algorithm for primary cytoreductive surgery (PCS) reduces perioperative mortality, however, nonlethal complications are common. This study identified procedures associated with postoperative complications in triage-appropriate women, with the aim of guiding the next steps to foster surgical quality improvement. Materials and Methods: Consecutive triage-appropriate women with stage IIIC/IV ovarian cancer undergoing PCS, from January 2012 to April 2018, were included. The expanded Accordion scale was used to grade complications. Adjusted risk ratios ( RRs ) were calculated to quantify the association between concomitant procedures and risk of 30-day grade 3+ (G3+) complications by fitting Poisson regression models adjusted for performance status and age. Population-attributable risk (PAR) was calculated based on the adjusted RR s and prevalence of each procedure. Results: Of 214 women, 82.7% had intermediate- or high-complexity surgery, 68.7% had complete gross resection, 3.7% had residual disease >1 cm, and 18.7% experienced G3+ complications. In univariate analysis, operative time, surgical complexity, splenectomy, and bowel resection (any and extent of) were associated with G3+ complications. Operative time, bowel resection (any, extent of, and large) were associated with G4+ complications. In the adjusted analysis for G4+ complications, bowel resection (any, extent of, and large) had statistically significant PAR values of 60.7%, 54.7%, and 50.8%, respectively. PAR values associated with G3+ complications were 27.4% and 26.8% for any and multiple bowel resections, respectively. Conclusions: Bowel resection, upper abdominal procedures, and longer operative times are essential for PCS, but each contributes to the relatively constant rates of postoperative morbidity despite triage to prevent frail patients from undergoing PCS. Surgical-improvement research should focus on improving the safety of these procedures. (J GYNECOL SURG 39:123)

Objective: To describe reported outcomes of nonsurgical radiologic interventions for abdominal wall endometriosis in comparison with surgery where available. Data sources: A systematic search of Ovid Medline, Embase, PubMed, and Cochrane Controlled Register of Trials was performed from inception to January 2019 with no language restrictions. Study eligibility criteria: Studies were included if they evaluated a nonsurgical intervention in women with symptomatic abdominal wall endometriosis with both comparative and noncomparative study designs. Study appraisal and synthesis methods: Titles and abstracts were reviewed for relevance, and full-text articles were obtained and evaluated for inclusion, all in duplicate. Meta-analysis was performed when possible using a fixed effects model. Results: Of the 114 records reviewed, 16 full-text articles were assessed and 7 were included in analysis. The standard mean difference between pre- and post-intervention pain scores was similar between ultrasound-guided high-intensity focused ultrasound (USgHIFU) (−3.00; 95% confidence interval −3.34, −2.66) and cryoablation (−3.93; 95% confidence interval −5.73, −2.12). The mean percent decrease in lesion size following intervention was similar between USgHIFU (−61.38%; 95% confidence interval −78.64%, −44.11%), and cryoablation (−88.16%; 95% confidence interval −83.90%, −55.06%). When compared with surgical excision, mean length of stay was 2.78 days less in the nonsurgical intervention group (95% confidence interval −3.78, −1.79). Conclusions: Both USgHIFU and cryoablation are effective at reducing pain scores and lesion size in abdominal wall endometriosis. Mean length of stay was significantly less following a nonsurgical radiologic intervention for abdominal wall endometriosis compared with surgery. More studies are needed comparing complication and recurrence rates between nonsurgical radiologic interventions for abdominal wall endometriosis and surgery.