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ABSTRACT: Venous thromboembolic events (deep vein thrombosis [DVT] and pulmonary embolism) are serious preventable complications associated with gynecologic surgery. Preoperative risk assessment of the individual patient will provide insight into the level of risk and the potential benefits of prophylaxis. Common risks include a history of venous thromboembolism, age, major surgery, cancer, use of oral contraceptives or hormone therapy, and obesity. Based on the presence of risk factors, the patient should be categorized into one of four risk groups and appropriate thromboprophylaxis prescribed. Randomized clinical trials in gynecologic surgery and general surgery have established the significant value of thromboprophylaxis. For moderate- and high-risk patients undergoing surgery for benign gynecologic conditions, low-dose unfractionated heparin, low molecular weight (LMW) heparins, intermittent pneumatic leg compression, and graded compression stockings all have demonstrated benefit. If using low-dose unfractionated heparin in high-risk patients, the heparin should be administered 5,000 units every 8 hours. Because DVT often begins in the perioperative period, it is important to initiate low-dose unfractionated heparin or administer the first LMW heparin dose either 2 hours preoperatively or 6 hours after the surgical procedure. Low molecular weight heparin has the advantage of being administered once daily but is more expensive than low-dose unfractionated heparin. In addition, LMW heparin has not been shown to be more effective and has similar risk of bleeding complications when compared with low-dose unfractionated heparin. In the very high-risk patient, a combination of two prophylactic methods may be advisable and continuing LMW heparin for 28 days postoperatively appears to be of added benefit.
Obstetrics and Gynecology 01/2012; 119(1):155-67. · 4.73 Impact Factor
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ABSTRACT: Thirty-three percent of U.S. women are either obese or morbidly obese. This is associated with an increased risk of death from all causes and is also associated with an increased risk of endometrial carcinoma. We sought to compare minimally invasive surgical techniques for staging the obese and morbidly obese woman with endometrial cancer.
Consecutive robotic endometrial cancer staging procedures were collected from 2005-2007 and were compared to consecutive laparoscopic cases (2000-2004). Demographics including age, weight, body mass index (BMI), operative time, estimated blood loss, lymph node retrieval, hospital stay and complications were collected and compared.
During the study period, there were 36 obese and 13 morbidly obese women who underwent surgery with the DaVinci robotic system and 25 obese and 7 morbidly obese women who underwent traditional laparoscopy. For both the obese and morbidly obese patient, robotic surgery was associated with shorter operative time (p=0.0004), less blood loss (p<0.0001), increased lymph node retrieval (p=0.004) and shorter hospital stay (p=0.0119).
Robotic surgery is a useful minimally invasive tool for the comprehensive surgical staging of the obese and morbidly obese woman with endometrial cancer. As this patient population is at increased risk of death from all causes, including post-operative complications, all efforts should be made to improve their outcomes and minimally invasive surgery provides a useful platform by which this can occur.
Gynecologic Oncology 08/2008; 111(1):41-5. · 3.89 Impact Factor
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ABSTRACT: Publication bias is the selective publishing of favorable or statistically significant results. This practice, over time, distorts the medical literature by depicting inordinately optimistic outcomes for treatments and interventions. Sources of publication bias include preferential publishing by journals and preferential submission by researchers. Mandatory trial registration, as instituted by the International Committe of Medical Journal Editors (ICMJE), should reduce publication bias by improving the ability to identify all trials pertaining to a specific intervention. Contraception endorses the views of the ICMJE and will now require registration of all prospective trials.
Contraception 12/2007; 76(5):339-41. · 2.72 Impact Factor
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ABSTRACT: Publication bias is the systematic, preferential publication of studies with statistically significant positive results over indeterminate studies (frequently, researchers inappropriately term these "negative" studies), or studies that show a statistically significant negative outcome. Over time, this practice distorts the medical literature, potentially compromising the validity of systematic reviews. Publication bias primarily stems from investigators, but data suppression can occur by pharmaceutical companies, universities, and regulatory agencies. Registration at inception of all clinical trials in a centralized, searchable database can reduce publication bias by enabling researchers to identify all studies related to a particular intervention. Prior attempts to encourage voluntary trial registration have been largely unsuccessful. Hence, the International Committee of Medical Journal Editors recently adopted a policy of mandatory clinical trial registration before consideration of manuscripts for publication. Trial registration and the development of comprehensive, computerized databases will promote transparency in research and help reduce publication bias.
Obstetrics and Gynecology 07/2007; 109(6):1434-7. · 4.73 Impact Factor
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ABSTRACT: To investigate whether improvements in sonographic technology would allow detection of embryonic demise at a crown-rump length (CRL) < 5 mm.
A prospectively collected, computerized ultrasound database was queried for singleton gestations with CRL < or = 5 mm from January 2000 to February 2003. Embryonic viability was determined by repeat ultrasound examination after 6 weeks'gestation confirming cardiac activity or by documentation of an ongoing pregnancy. Viability rates in the presence or absence of cardiac activity were calculated for CRL of 2.0-2.9, 3.0-3.4, 3.5-3.9, 4.0-4.4, 4.5-4.9 and 5.0 mm. Sensitivity, specificity, positive predictive value and negative predictive value for embryonic demise were calculated, with a subanalysis based on the presence of vaginal bleeding.
Outcome was available for 179 of 195 gestations meeting inclusion criteria. The absence of cardiac activity at CRL > or = 3.5 mm had 100% positive predictive value and specificity. The presence of vaginal bleeding did not affect this cutoff.
Improved sonographic technology permits diagnosis of embryonic demise at a CRL > or = 3.5 mm under ideal conditions. Vaginal bleeding increases the likelihood of demise, but does not alter test performance. Further investigation is warranted, as our data suggest a limit closer to 3 mm.
The Journal of reproductive medicine 06/2007; 52(5):375-8. · 0.87 Impact Factor
