Dexamethasone for reduction of nausea, vomiting and analgesic use after gynecological laparoscopic surgery.

OBJECTIVE: To evaluate the prophylactic use of dexamethasone for reducing postoperative nausea and vomiting (PONV) and analgesic use after gynecological laparoscopic surgery. METHODS: In a prospective randomized, double-blind, placebo-controlled trial, 90 women received either intravenous placebo, 4 mg dexamethasone or 8 mg dexamethasone at the end of surgery. PONV and analgesic requirements were evaluated. RESULTS: The rate of patients experiencing PONV within 24 h after anesthesia was 53% in the 4 mg dexamethasone group (P=0.3) and 20% in the 8 mg dexamethasone group (P=0.001), compared with the placebo group (63%). Requests for indomethacin to relieve intolerable pain were less in patients in the 8 mg dexamethasone group compared with the 4 mg dexamethasone (P=0.047) or placebo (P=0.029) groups. CONCLUSION: Prophylactic use of 8 mg dexamethasone is effective for reducing PONV and analgesic requirements after gynecological laparoscopic surgery.     

Prevention of nausea and vomiting during termination of pregnancy

Background

Postoperative nausea and vomiting (PONV) is common in women undergoing dilatation and curettage under general anesthesia for pregnancy termination, and many studies suggest treating these women prophylactically for PONV.

Objectives

Reviewing the antiemetics used over the past 20 years for this indication and comparing their efficacy.

Search strategy

We performed MEDLINE and EMBASE searches for articles published from January 1980 through June 2009. The search terms were complications, nausea, vomiting, antiemetics, anesthetics, surgery, dilatation, curettage, pregnancy, and women.

Selection criteria

We selected the studies of the antiemetics droperidol, metoclopramide, hydroxyzine, propofol, dexamethasone, ondansetron, and ramosetron when used for the stated indication. When assessing drug efficacy, we compared the antiemetics used at the time the article was written.

Data collection and analysis

We reviewed the selected studies, presented the reported incidence rates of PONV for each drug, and presented and interpreted the P values reported for the different comparisons.

Main results

Although all antiemetics assessed decreased the incidence of PONV, the combination of dexamethasone and droperidol seems to be the most effective in preventing PONV.

Conclusions

All antiemetics used in the last 20 years to prevent PONV are effective (some more than others) in women undergoing dilatation and curettage for pregnancy termination. However, there is a need for benefit and risk analyses of the different treatments.     

Recall bias of the symptoms of nausea and vomiting of pregnancy

OBJECTIVE: Nausea and vomiting of pregnancy is the most common medical condition in pregnancy. Relatively little research has been conducted on this condition, and much of it is based on women's reports. Determinants that affect women's reports of their nausea and vomiting of pregnancy symptoms have not been elucidated. The purpose of this study was to assess the accuracy of recall by women of their symptoms of nausea and vomiting of pregnancy. STUDY DESIGN: Two hundred women who called the Motherisk nausea and vomiting of pregnancy counseling line in Toronto were asked about the severity of their nausea and vomiting of pregnancy symptoms with the use of the pregnancy unique quantification of emesis and nausea system (PUQE). The patients were asked the same questions again during a follow-up call, which took place up to 16 weeks later. RESULTS: There was a recall (or reporting) bias for nausea and vomiting, with women reporting significantly more severe symptoms during their follow-up call than they had reported originally. Multivariate analysis revealed that the severity of the symptoms affected the accuracy of recall positively, whereas the time that has elapsed affected it negatively. CONCLUSION: Retrospective evaluation of nausea and vomiting of pregnancy symptoms may produce a recall bias, which may distort the evaluation of the therapeutic effectiveness of antiemetics.     

Risk factors for prolonged hospitalization after gynecologic laparoscopic surgery

Objective

To determine perioperative risk factors for prolonged hospitalization after gynecologic laparoscopic surgery.

Methods

Data on patients who underwent gynecologic laparoscopic surgery at a single academic institution from January 2000 to January 2009 were evaluated. Patient demographics, clinical history, intraoperative data, and postoperative adverse events were analyzed. Logistic regression analysis identified significant predictors of prolonged hospitalization (hospital stay > 48 h after surgery). A risk score was created from the analysis to predict prolonged hospitalization.

Results

Eight hundred seven patients were included. The median body mass index was 26.5 kg/m² (range, 14.2-72.3 kg/m²), and the median age was 49 years (range, 12-88 years). Four hundred fifty-nine patients (56.9%) underwent surgery for benign conditions, and 348 (43.1%) underwent surgery for malignant disease. A total of 78 patients (9.7%) had a prolonged hospitalization. Independent predictors of prolonged hospitalization were age > 54 years (P < 0.0001), operative blood loss > 120 mL (P < 0.0001), intraoperative or postoperative blood transfusion (P = 0.0237), and early postoperative complication (P < 0.0001). Having a prior laparoscopy was associated with a shorter hospital stay (P = 0.0276). The risk score showed how changes in perioperative factors change the risk of prolonged hospitalization.

Conclusion

Factors such as age, blood loss, perioperative blood transfusion, and postoperative complications are associated with prolonged length of stay after laparoscopic surgery, while having a prior laparoscopy is associated with a shorter hospital stay. A clinical scoring system can be used to estimate probability of prolonged hospitalization after gynecologic laparoscopic surgery.     

Can centralised care of complex laparoscopic procedures prevent urinary tract injuries?

Centralised care of complex laparoscopic procedures offers expertise and multidisciplinary care. The objective was to identify if centralised care makes urinary tract injuries less likely or avoidable. This Retrospective Audit was performed at a Tertiary Referral Centre for Advanced Laparoscopic Surgery in North East England. The incidence of injury to bladder/ureter, time of diagnosis, instrument, location, side and mode of repair were evaluated in 105 consecutive complex laparoscopic procedures. Injuries were identified in three (2.8%) cases. There was one bladder injury which was unavoidable. The bladder dome was opened to allow excision of bladder endometriosis. There were two ureter injuries. The first injury involved the ureter being locked in a vaginal vault stitch. The second injury had stage IV endometriosis with peri-ureteric endometriosis where the anatomy was distorted, with medial displacement and kinking of the ureter secondary to fibrosis at the level of the ureter crossing below the uterine artery, with resultant accidental transection of the ureter close to the uterine artery. The first ureter injury was not a laparoscopic injury but due to vaginal vault closure. Arguably, vault closure in any vaginal hysterectomy could carry the same theoretical risk. The only direct laparoscopic injury was the ureteral transection. Such cases present a challenge due to a higher chance of anatomical distortion and predisposition to urinary tract injury. Noteworthy here is the fact that the ureter injury occurred where there was probable distortion of the anatomy, due to endometriosis, of the ureter at the level of the uterine artery. These cases are tackled by experienced laparoscopic surgeons in tertiary centres, yet injuries still occur. Is it possible then that those injuries represent a minimum unavoidable injury rate, and are they injuries or in fact unavoidable consequences of such inherently dangerous and difficult surgery?     

围手术期干预对妇科盆腔手术后下肢深静脉血栓的预防作用

目的 探讨采取围手术期干预措施对妇科盆腔手术后下肢深静脉血栓(DVT)的预防作用.方法 将2007年6月至2008年6月于浙江大学医学院附属邵逸夫医院妇产科接受妇科盆腔手术的1062例患者分为干预组和非干预组.对干预组患者进行DVT危险因素评分,根据评分情况分为低、中、高和极高危4种类型,分别采取相应的围手术期干预措施.两组所有患者如术后7 d内出现下肢自发性疼痛、压痛和肿胀,腓肠肌压迫试验或直腿伸踝试验阳性,合并或存在单侧下肢浅表静脉扩张,立即行双下肢静脉彩色多普勒超声检查;干预组中高危和极高危患者于术后第2天和第7天常规行双下肢静脉彩色多普勒超声检查.比较两组患者的DVT发生率,以及手术前后的凝血和纤溶功能等.所有患者在术前1周内、术后48 h时分别检测凝血及纤溶功能.结果 干预组6例发生DVT,发生率为1.10%(6/546);非干预组17例发生DVT,发生率为3.29%(17/516);两组间DVT总发生率比较,差异有统计学意义(P<0.05).干预组中DVT极高危患者的DVT发生率为21.05%(4/19),均分别高于低危(0)、中危(0)、高危者[2.13%(2/94)],差异均有统计学意义(P<0.05).两组患者术后D二聚体及抗凝血酶Ⅲ水平均分别高于术前水平,但差异均无统计学意义(P>0.05).两组患者术后血小板计数、凝血酶原时间、活化部分凝血活酶时间、凝血酶时间及纤维蛋白原、组织型纤溶酶原活化剂、纤溶酶原活化剂抑制剂水平分别比较,差异也均无统计学意义(P>0.05).结论 根据不同的DVT危险分群采取相应围手术期干预能显著降低DVT的发生率,建议加强对高危及极高危人群的DVT预防.     

A randomized trial of chewing gum to prevent postoperative ileus after laparotomy for benign gynecologic surgery

Objective

To assess whether chewing gum prevents postoperative ileus after laparotomy for benign gynecologic surgery.

Methods

A randomized study was conducted from December 1, 2010, to February 29, 2012. Patients scheduled to undergo laparotomy were randomly assigned to receive chewing gum or routine care after surgery. A chart review was performed to establish incidence of nausea and vomiting, use of antiemetics, cases of postoperative ileus (≥ 2 episodes of emesis of 100 mL or more, with abdominal distention and absence of bowel sounds), and time to discharge. Inpatient surveys recorded the time to specific events.

Results

A total of 109 patients were randomly assigned to receive chewing gum (n = 51) or routine postoperative care (n = 58). Fewer participants assigned to receive chewing gum than routine care experienced postoperative nausea (16 [31.4%] versus 29 [50.0%]; P = 0.049) and postoperative ileus (0 vs 5 [8.6%]; P = 0.032). There were no differences in the need for postoperative antiemetics, episodes of postoperative vomiting, readmissions, repeat surgeries, time to first hunger, time to toleration of clear liquids, time to regular diet, time to first flatus, or time to discharge.

Conclusion

Chewing gum after laparotomy for gynecologic surgery is safe and lowers the incidence of postoperative ileus and nausea.ClinicalTrials.gov:NCT01579175     

Effect of acupressure on nausea and vomiting during pregnancy

This paper sought to determine the efficacy of acupressure application in pregnant women suffering from nausea, with or without associated vomiting, who were unable to receive conventional medication for these symptoms. Sampling consisted of pregnant women complaining of nausea with or without vomiting. The study was controlled by the Maternity and Child Hospital in Istanbul between March 2004 and March 2005. The treatment group comprised 26 women; 25 in the control arm and 24 women were assigned to the placebo arm. The study occurred over a 9-day period. During this time, the treatment group applied acupressure bands to P(6) acupressure point on days 4-6 of the study with the placebo group receiving acupressure bands to a sham acupressure point, on the upper side of their wrists. RESULTS AND CONCLUSION: Acupressure would appear to be effective in symptom control, and alleviation and placebo effects in reducing the symptoms of nausea and vomiting during pregnancy.     

The effects of listening to music on the postoperative nausea and vomiting

AimTo determine the effect of music on the severity of postoperative nausea and vomiting after the laparoscopic cholecystectomy.MethodsThis study was a randomized, controlled clinical study. The subjects were randomly divided into two groups (intervention group and control group). The numerical scale of nausea was used in rating the nausea complaints of the patients and the vomiting incidence assessment form in determining the incidence of vomiting.ResultsThere were statistically significant difference between the groups in terms of the severity of nausea complaint (W = 110.826 p < 0.001). When compared to the control group, the vomiting incidence of the patients was statistically significantly lower in intervention group.ConclusionsThis study demonstrated that listening to music decreased the severity nausea and the incidence of vomiting in the postoperative period.     

Dual-console robotic surgery compared to laparoscopic surgery with respect to surgical outcomes in a gynecologic oncology fellowship program

Objective

Minimally invasive surgical techniques decrease surgical morbidity and recovery time. Studies demonstrate similar surgical outcomes comparing robotic to laparoscopic surgery. These studies have not accounted for the incorporation of fellow education. With the dual-console da Vinci Si Surgical System®, a two surgeon approach could be performed. We sought to compare surgical outcomes at a gynecologic oncology fellowship program of traditional laparoscopic to robotic surgeries using the dual-console system.

Methods

We identified patients who underwent laparoscopic or robotic surgery performed by a gynecologic oncologist from November 2009-November 2010. Robotic surgeries were conducted using the dual-console, utilizing a two surgeon approach. Surgeries involved a staff physician with a gynecologic oncology fellow. Statistical analysis was performed using student t-test and chi-squared analysis.

Results

A total of 222 cases were identified. Cases were analyzed in groups: all cases identified, all cancer cases, and endometrial cancer cases only. When analyzing all cases, no statistical difference was noted in total operating room time (172 vs. 175 min; p = 0.6), pelvic lymph nodes removed (10.1 vs. 9.6; p = 0.69), para-aortic lymph nodes dissected (3.7 vs. 3.8; p = 0.91), or length of stay (1.5 vs. 1.3 days; p = 0.3). There was a significant difference in total surgical time (131 vs.110 min; p < 0.0001) and EBL (157 vs.94 ml; p < 0.0001), favoring robotic surgery. When analyzing all cancer cases, the advantage in total surgical time for robotic surgery was lost. Complications were similar between cohorts.

Conclusion

Incorporating fellow education into robotic surgery does not adversely affect outcomes when compared to traditional laparoscopic surgery.     

妇科腹腔镜手术1560例临床分析

目的：探讨腹腔镜手术在妇科的临床应用价值。方法：1997～2002年对1560例腹腔镜手术者均采用全麻；异位妊娠术式为输卵管切除术、输卵管伞端取胚术及输卵管造口术；卵巢囊肿手术采用剔除术、剥除术及患侧附件切除术；子宫手术采用改良式CISH术、子宫次全切除术、子宫全切术及LAVH术；主要器械为单双极电凝及超声刀。结果：腹腔镜手术占同期妇科手术的45．28％，手术成功率99．55％，发生并发症7例(0．45％)。结论：适应证掌握得当。妇科大部分手术可在腹腔镜下完成。     

Evidence-based prophylaxis strategies for postoperative nausea and vomiting when considering ethnicity factor

In most western countries, postoperative nausea and vomiting (PONV) is an important issue and prophylaxis guideline for PONV will be followed in clinical practice. We tried to conduct a review study and a local study to elucidate the incidence and severity of PONV to see if considering ethnicity factor, should we still need to follow those prophylaxis guidelines from western countries. The PubMed, and MEDLINE were consulted from January 2000 to 2018 and also Cochrane Central Register of Controlled Trials (CENTRAL 2010). The key word for searching is PONV (incidence, severity and prevention strategy), without language limitation and focus on Asian countries. The results showed that the overall incidence and severity of PONV in Asian countries was less significant than in western countries. PONV in western countries could be a serious issue and prophylaxis strategy adjusted by Apfel score could be adopted in routine practice. After this review consultation, the issue of PONV in different ethnic countries (including Taiwan) might be over emphasized and we may suggest not to follow west countries PONV prophylaxis guideline as our routine practice.     

Use and misuse of opioid after gynecologic surgery

Postoperative opioid use following gynecologic surgery may be necessary for effective treatment of pain; however, it can result in significant side effects, adverse reactions, and negative health consequences, including prolonged problematic use. Surgeons and healthcare providers of patients recovering from gynecologic procedures should be aware of effective strategies that can decrease the need for opioid use, while providing high-quality pain management. These include adherence to Enhanced Recovery After Surgery Protocols, particularly the use of multimodal analgesia management. When prescribing opioids, providers should adhere to responsible prescribing practices to minimize the risk of inappropriate and/or long-term opioid use.     

腹腔镜手术并发症34例分析

目的 探讨腹腔镜手术的并发症及其相关因素。方法 回顾性分析北京协和医院妇产科近6扑的1769例腹腔镜手术病例及34例出现并发症的病例情况。手术包括附件手术1421例，子宫肌瘤剔除术52例，腹腔镜辅助的阴式子宫切除术296例，并发症指术中出现的需额外处理或术后出现的因手术术身引起需行再次手术或保守治疗的情况。结果 并发症发生率为1.9%，需开腹手术处理者6例（0.3%)。附件手术、肌瘤剔除术及阴式子宫切除术的并发症发生率分别为0.9%、1.9%及6.8%。与穿刺及气腹有关的并发症12例（35.3%)，包括腹壁血管、大网膜血管损伤及严重的皮下气肿；术中并发症5例（14.7%)，其中大出血3例，膀胱破裂1例，均改开腹手术，另1例为负极板放置处大腿皮肤烧伤；术后并发症17例（50.0%)，其中2例术后腹腔内出血再次开腹止血，术后并发症还包括肠道并发症、神经麻痹及发热。结论 妇科腹腔镜手术的并发症不容忽视，并发症的发生与手术的难度有关。阴式子宫切除术并发症的发生远高于附件手术及子宫肌瘤剔除手术。     

Spread of ovarian cancer after laparoscopic surgery: report of eight cases

OBJECTIVE: The aim of this study was to describe early occurrences of metastases after laparoscopy of ovarian masses later found to be malignant. METHODS: The hospital charts of eight women having undergone laparoscopic surgery for ovarian mass were reviewed and analyzed. RESULTS: The mean age of the patients was 40 years (range 25 to 66). Size of the tumor ranged from 2 to 15 cm. In four patients the ovarian mass was suspected to be malignant in the laparoscopy. Diagnostic procedure (biopsy of the tumor) was performed in two and salpingo-oophorectomy in six patients. Staging laparotomy was performed within the mean of 17 days (range 7-29). In four patients (50%) the cancer had spread from a localized to an advanced stage during the delay. Ascites was present in the laparoscopy in two of the four patients with port site or abdominal wall metastases. CONCLUSIONS: Laparoscopic surgery of ovarian mass later found to be malignant can cause considerable and early spread of the cancer.     

基层医院妇科腹腔镜手术并发症55例临床分析

目的探讨基层医院妇科腹腔镜手术类型、并发症发生原因和防治方法 ,提高手术的安全性。方法对北京市昌平区中医医院2002年5月至2010年5月进行的758例妇科腹腔镜手术的临床资料作回顾性分析。结果 758例腹腔镜手术中,发生并发症55例,占7.26%。其中持续性宫外孕3例、大出血8例、输尿管损伤1例、膀胱损伤2例、盆腔化脓性感染2例,皮下气肿20例、腹壁瘀血19例。并发症中需开腹处理13例,再次腹腔镜手术1例。结论基层医院腹腔镜手术应循序渐进,在技术条件不允许的情况下不宜开展难度大的内镜手术。     

Effect of acupressure by Sea-Bands on nausea and vomiting of pregnancy

OBJECTIVE: To determine the effect of continuous acupressure at P6 applied by Sea-Bands with acupressure buttons on the frequency and severity of nausea and vomiting of pregnancy during the 1 st trimester. DESIGN: A two-group, quasi-experimental, posttest-only and posttest-repeated measure. SETTING: Seventeen medical clinics or offices in southern Michigan. PARTICIPANTS: Convenience sample of English-speaking, healthy pregnant women in their 1 st trimester, who had at least one episode of nausea, vomiting, or both before their prenatal clinic/office visit where they were recruited. After being accepted for the study, the women were randomly assigned to treatment or placebo groups. INTERVENTION: Treatment group 1 applied SeaBands with acupressure buttons to both wrists for 4 days and removed the Sea-Bands for 3 subsequent days. Placebo group 2 applied the Sea-Bands without acupressure buttons to both wrists on the same time schedule as group 1. MAIN OUTCOME MEASURE: Self-report daily diaries of the number of times per day that participants experienced nausea, the severity of nausea, the number of vomiting episodes per day, and the severity of vomiting. RESULTS: Mann-Whitney U procedures revealed that the treatment group had significantly less frequency and severity of nausea and vomiting of pregnancy while wearing the Sea-Bands than did the placebo group. The treatment group also had significantly less frequency and severity of nausea and vomiting of pregnancy while wearing the SeaBands than when not wearing the Sea-Bands. CONCLUSIONS: Sea-Bands with acupressure buttons are a noninvasive, inexpensive, safe, and effective treatment for the nausea and vomiting of pregnancy.     

A randomized blinded study of the incidence of postoperative nausea and vomiting in women after major gynecologic laparoscopic surgery

STUDY OBJECTIVE: To estimate the incidence of postoperative nausea and vomiting (PONV) in women undergoing major gynecologic laparoscopic surgery with an expected surgical duration exceeding 1 hour and anticipated overnight hospitalization. DESIGN: Randomized, double-blind, placebo-controlled study. SETTING: This study was set at a university hospital. PATIENTS: One hundred forty female patients with an American Society of Anesthesiology (ASA) physical status I or II and scheduled for gynecologic inpatient laparoscopic surgery. INTERVENTIONS: Patients were randomly assigned to receive 1 mg granisetron (Group A, n=70), or saline solution (Group B, n=70) intravenously after induction of general anesthesia. MEASUREMENTS AND MAIN RESULTS: The endpoints were evaluated by the following parameters: the incidence of PONV, episodes of nausea, retching, vomiting, rescue antiemetics, and complete response. Patients were closely observed for 24 hours after administration of the study drug. The two groups were generally well balanced in terms of demographic variables. The surgical period was longer in the granisetron group compared with the saline solution group. The total incidence of PONV was 41/70 (59%) in patients who underwent inpatient gynecologic laparoscopic surgery when no prophylactic antiemetic was given. Administration of granisetron decreased the incidence of PONV (29/70 [41%] vs 41/70 [59%], p<.05), the incidence of vomiting (18/70 [26%] vs 31/70 [44%], p<.05), and the proportions of patients requiring rescue antiemetics (14/70 [20%] vs 47/70 [67%], p<.01), but these results were not comparable to other studies. CONCLUSION: A long surgical period may have great impact on the PONV in women who undergo gynecologic laparoscopic surgery, which implies the need for skilled gynecologic laparoscopists.