Charlotte Møller

Fast track hysterectomy

Abstract Objective : To identify factors limiting early discharge after laparoscopically assisted vaginal hysterectomy (LAVH) and abdominal hysterectomy, in a fast track setting with emphasis on information, treatment of pain, early mobilization, and early food intake. Study Design : A prospective, descriptive study of 32 unselected women allocated to either abdominal hysterectomy ( n =16) or LAVH ( n =16). The patients received the same information, care, and advice for the perioperative period except for an assumed 1-day hospital stay in the LAVH-group and 2 days in the abdominal group. Results : Patients were discharged median 1 day (1–3) after LAVH and 2 days (2–4) after abdominal hysterectomy. Work was resumed median 23 days after abdominal hysterectomy and 28 days after LAVH ( P >0.05). Conclusions : The study questions the previously proposed advantages of shortened hospitalization and convalescence after LAVH compared with abdominal hysterectomy. Further studies with active rehabilitation are needed to demonstrate real differences between laparoscopic and open hysterectomy.

ABO blood groups and risk of venous thromboembolism during pregnancy and the puerperium. A population‐based, nested case–control study

Summary.  Objectives: To examine possible associations of ABO blood types with the risk of venous thromboembolism (VTE) in pregnancy and the puerperium. Patients and methods: We conducted a nested case–control study within a cohort of 71 729 women who gave birth to 126 783 children in the North Jutland County, Denmark, from 1980 to 2001. We identified 129 cases with VTE in pregnancy (n = 61) or the puerperium (n = 68), and 258 controls with no VTE. We collected information on ABO blood groups and possible maternal confounding factors and estimated the relative risk [odds ratio (OR)]. Results: Women with an A or AB blood group had elevated risk estimates of VTE in pregnancy or the puerperium compared with women with a O blood group [adjusted ORs 2.4, 95% confidence interval (CI) 1.3, 4.3, and 2.0, 95% CI 0.7, 5.8, respectively]. No increased risk estimate was found for group B (adjusted OR 1.2, 95% CI 0.5, 3.0). The increased risk estimates of VTE for blood groups A and AB appeared present in both pregnancy (adjusted ORs of 3.9, 95% CI 1.5, 9.7, and 2.2, 95% CI 0.4, 12.5) and in the puerperium (adjusted ORs of 2.4, 95% CI 1.0, 4.9 and 2.7, 95% CI 0.8, 9.3). Furthermore, blood groups A and AB appeared to be associated with increased risk estimates for both DVT and pulmonary embolism. Conclusion: Keeping the modest statistical precision of our study in mind, blood groups A and AB may be associated with increased risk estimates for VTE in pregnancy and the puerperium.

Establishment of a national Danish hysterectomy database: Preliminary report on the first 13,425 hysterectomies

Objective. To describe the concept and early results from the Danish Hysterectomy Database (DHD). Design. Nationwide prospective cohort. Setting. Denmark. Population. All women who had undergone an elective hysterectomy for benign indication carried out in 2004–2006. Methods. Structured data are registered prospectively by the surgeons involved in the treatment. Data is reported using the Danish National Patient Registry (LPR) and feedback is provided as clinical indicators with well‐defined goals. The DHD concept includes annual plenary meetings, elaboration of national clinical guidelines and parallel causal studies. Main outcome measures. Completeness, data validation and department‐identifiable clinical indicators (surgical volume, method of hysterectomy, use of antibiotic and thromboembolic prophylaxis, postoperative hospitalization and bleeding complications, surgical infections, reoperations, readmissions and death within 30 days postoperatively). Results. A total of 13,425 hysterectomies were performed in Denmark from 2004 to 2006. In 2005, all gynecological departments in Denmark (n = 31) were included in the database collaboration and the national response rate was 99%. Data validity was good in general (82–100% agreement and κ = 0.40–1.00) and data completeness was high (92–100% in 2006). From 2004 to 2006, two clinical guidelines were implemented, the postoperative hospitalization was stable at median 2 days, the rate of postoperative surgical infections was reduced from 4 to 2%, the rate of bleeding complications from 8 to 6%, the reoperation rate from 5 to 4%, and the readmission rate from 7 to 5%. Conclusions. Clinical performance indicators, audit meetings and nationwide collaboration are useful in monitoring and improving outcome after hysterectomy on a national level. In addition, the DHD offers scope for causal studies about perioperative management.

Substantial variability in postoperative treatment, and convalescence recommendations following vaginal repair. A nationwide questionnaire study

Background. Postoperative care and convalescence recommendations following vaginal surgery are generally not evidence based. The aim of this study was to describe pre and postoperative treatment, and advice and restrictions for the convalescence period, given by Danish hospital‐employed gynecologists, and gynecologists in private practice, to patients undergoing vaginal repair.

Preoperative staging of endometrial cancer using TVS, MRI, and hysteroscopy.

To evaluate the accuracy of different preoperative modalities for staging of endometrial cancer to restrict extensive surgery to patients at high risk of metastatic disease.

An ultrasound algorithm for identification of endometrial cancer.

To propose a scoring system to predict endometrial cancer using different ultrasound image characteristics at gray‐scale, with and without enhancement by gel infusion, and Doppler transvaginal sonography (TVS) and to evaluate intra‐ and interobserver variability in assessment of these characteristics.

Timing of heparin prophylaxis and bleeding complications in hysterectomy a nationwide prospective cohort study of 9,949 Danish women

Objective. To examine bleeding complications and thromboembolic events in relation to timing of heparin prophylaxis after hysterectomy. Design. Nationwide prospective cohort study with 30 days post‐operative follow‐up within the Danish Hysterectomy Database (DHD). Setting. All gynecological departments in Denmark (n = 31). Sample. 9,949 women who had an elective hysterectomy for benign indication between October 2003 and May 2006 and were reported to DHD (national response rate: 88–99% throughout 2004–2005). Main outcome measures. Odds ratios (OR) of peri‐operative bleeding complications (≥1,000 ml bleeding during surgery or post‐operative wound/vaginal‐vault/intraabdominal bleeding or hematoma) and number of events of venous thromboembolism. Logistic regression analysis adjusting for: age, body mass index, alcohol, smoking, meno‐/metrorrhagia, uterine weight, department volume, surgeons experience, route and type of hysterectomy and additional surgery, and stratification on assistants experience, peri‐operative pain prophylaxis with NSAID and daily use of Acetyl Salicylic Acid (ASA)/NSAID. Results. 9,051 women (92%) received thromboprophylaxis with heparin, initiated pre‐operatively in 48% and post‐operatively in 52%. At least one bleeding complication was noted in 881 women (10%). Post‐operative heparin administration was associated with a reduced risk of bleeding complications; OR=0.85 (95% confidence interval 0.73–0.99) compared to pre‐operative administration. Excluding cases with potential impaired hemostasis at baseline, the OR was 0.78 (0.64–0.94). There was no fatal embolism. Three of seven pulmonary embolisms and one of three symptomatic deep venous thromboses occurred with the post‐operative heparin administration. Conclusion. Post‐operative rather than pre‐operative administration of heparin prophylaxis may reduce the risk of bleeding complications after hysterectomy without apparent risk of increased thromboembolic events.

Diagnostic methods for fast-track identification of endometrial cancer in women with postmenopausal bleeding and endometrial thickness greater than 5 mm.

ObjectiveThis study aims to evaluate the diagnostic efficiency of pattern recognition by transvaginal ultrasonography (TVS) and gel infusion sonography (GIS) for identifying endometrial pathology and to compare this setup with a standard setup of endometrial sampling (ES), hysteroscopy with pattern evaluation (HYpattern), or magnetic resonance imaging (MRI). MethodsThis study used a prospective cohort of 174 women with postmenopausal bleeding and endometrial thickness of 5 mm or greater. Resectoscopic biopsy (hysteroscopy with biopsy) samples or hysterectomy served as reference standard. Malignant and benign endometrial patterns were evaluated with TVS, GIS and HYpattern were then added. The efficiency of each diagnostic strategy, including ES and MRI findings (n = 83), was compared and evaluated against the reference standard. ResultsES, TVS, GIS, and HYpattern had high diagnostic efficiency (area under the curve) for malignancy diagnosis (ES, 0.90; TVS, 0.88; GIS, 0.92; HYpattern, 0.91). When insufficient samples were incorporated, ES was less efficient than the other techniques. ES was not more efficient in the subgroup of women without localized lesions than in the subgroup of women with localized lesions. MRI and HYpattern added limited efficiency, whereas hysteroscopy with biopsy was most efficient. ConclusionsAs a first-line technique, pattern recognition on TVS, GIS, and HYpattern correctly identifies 9 of 10 women with malignancy and is superior to pattern recognition on ES when insufficient samples are included. Endometrial pattern evaluated with TVS and GIS is a fast and efficient first-line diagnostic tool that outperforms ES in women with or without localized lesions. Malignant patterns on TVS/GIS should warrant fast-track evaluation, whereas women with benign patterns may be selected for office or operative hysteroscopy. A fast-track diagnostic setup based on pattern recognition is presented.