| 1. |
- Serreyn Lundin, Evelyn, 1969-
(författare)
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On Quality Improvement in Gynaecological Cancer Surgery
- 2020
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Objectives: The overall purpose of this thesis was to find medical and surgical treatment methods of improving the perioperative care of gynaecological cancer patients. The specific objectives were to determine whether a single dose tranexamic acid given immediately before surgery for presumed advanced ovarian cancer reduces perioperative blood loss and the need for blood transfusions, and to determine whether postoperative recovery, tissue damage, and inflammatory response markers differ between women operated with robotic and abdominal hysterectomy for low-risk endometrial cancer in an enhanced recovery after surgery (ERAS) programme, and to evaluate costs for hospital stay and postoperative recovery in relation to health impact. Material and Methods: The thesis was based on two randomised trials. The first trial was a randomised double-blind placebo-controlled multicentre study conducted in four hospitals in the southeast and central of Sweden between March 2008 and May 2012. One hundred women with presumed advanced ovarian cancer who had been scheduled for radical debulking surgery were included; 50 received tranexamic acid and 50 received a placebo. The main outcomes were blood loss and red blood cell transfusions. The second trial was a randomised open single centre trial at a Swedish university hospital, which included 50 women with low-risk endometrial cancer scheduled for radical surgery between February 2012 and May 2016; 25 women underwent robotic hysterectomy and 25 had abdominal hysterectomy. Anaesthesia and perioperative care followed an ERAS protocol in both groups. The EuroQol Group form EQ-5D-3L and the Short Form-36 evaluated the health-related quality of life. The Swedish Postoperative Symptoms Questionnaire assessed symptoms perioperatively until six weeks postoperatively. Venous blood samples were collected on several occasions until six weeks postoperatively and were analysed for markers reflecting inflammatory response and tissue damage. In addition, a health economic evaluation was conducted comparing total costs, qualityadjusted life years (QALYs) and cost per QALY between the surgical methods. Results: Total blood loss volume and transfusion rate following surgery in advanced ovarian cancer were significantly lower in the tranexamic group compared with the placebo group. Women with early endometrial cancer treated by robotic hysterectomy recovered significantly faster in the EQ-5D health index, and reached their preoperative level nearly two weeks earlier than the abdominal group. Differences regarding improvement in health-related quality of life (Short Form-36) comprising general health and social functioning were more favourable in the robotic hysterectomy group. Consumption of analgesics, pain intensity, postoperative symptom sum score and length of hospital stay were equal between the groups. The occurrence of complications was an independent risk factor and influenced most of the outcome measures adversely. Postoperative inflammatory response and tissue damage were lower after robotic hysterectomy compared with the abdominal approach. The robotic group gained more QALYs until six weeks after surgery than the abdominal group but the total costs were higher. The total cost per QALY gained was quite high for the robotic procedure. Conclusions: A single dose of tranexamic acid given immediately before surgery reduces blood loss and transfusion rates in advanced ovarian cancer surgery. Robotic hysterectomy in an ERAS programme treating early endometrial cancer leads to a faster recovery in the health-related quality of life than abdominal hysterectomy, the latter being strongly influenced by perioperative complications. Less tissue damage and inflammation might contribute to a faster recovery in the robotic group. Robotic hysterectomy provides more QALYs until six weeks postoperatively but with a substantially higher total cost for the society.
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| 2. |
- Crafoord, Kristina, 1950-
(författare)
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Genital prolapse surgery : A study of methods, clinical outcome and impact of pelvic floor muscle function
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Objective: To evaluate whether a shift in the extent of genital prolapse surgery occurred between 1983 and 1993. If such a shift occurred, the need for subsequent prolapse surgery; the prevalence of symptoms of pelvic floor dysfunction (PFD) in women six years after vaginal prolapse surgery. And also to analyze predictive factors and the subjective and objective outcomes of prolapse surgery at long term follow up. To evaluate whether neurophysiologic findings of the pelvic floor muscles and anorectal manometry measurements respectively are associated with pre- and postoperative symptoms and the extent of prolapse.Methods/material: A retrospective study of 542 consecutive patients, operated on for genital prolapse, with primary surgery during 1983 and 1993 in three Swedish hospitals was conducted. Data were obtained from the patient records and were analyzed with emphasis on demographic, clinical and surgical data. A postal questionnaire with validated questions concerning symptoms of PFD was in 1999 sent to women operated in 1993 for primary POP and no subsequent POP surgery.A prospective study of 42 women with genital prolapse, stage 2-3, scheduled for vaginal prolapse surgery was carried out. Preoperatively the women were examined with anorectal manometry, pudendal nerve neurography and concentric needle electromyography of the pubococcygeus muscles and the external anal sphincter muscle. Posterior colporrhaphy was part of the prolapse surgery in all women. Anatomical and subjective outcomes were evaluated six years postoperatively.Results: A shift from complete to selective repairs was seen between the two time periods, and posterior repair was often omitted in the latter period. The prevalence of subsequent prolapse surgery increased in the 1990s and the increase was more common in women with a selective repair than in those with complete repair. At long term, PFD-symptoms commonly occurred and were found to be associated with the extent of the prolapse surgery. Symptoms of prolapse and bowel emptying improved significantly after POP surgery in the prospective study. The cure rates of rectocele and apical descent were high, but low concerning cystocele. The results of the neurophysiologic investigations and anal sphincter pressures showed associations with the symptoms and the extent of the prolapse; the individual characteristics showed no discriminatory values.Conclusion: The extent of the surgical prolapse procedures changed between the two study periods and the extent of subsequent surgery also was greater in the second period. Symptoms of PFD and recurrence of prolapse, especially of the anterior compartment, were frequently seen. Prolapse and bowel symptoms were associated with the function of pelvic floor muscles but neither the results of the neurophysiologic nor the anorectal manometry measurements of the pelvic floor muscles were found to predict anatomical or subjective outcomes of POP surgery. More knowledge is needed of the pathophysiology of PFD in order to develop better means of prevention and to optimize treatment of POP. Development of new methods for identifying all defects of the pelvic floor and surgical techniques for restitution is also warranted for improving outcome of surgical treatment of genital prolapse.
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| 3. |
- Kassymova, Gulnara, 1972-
(författare)
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The impact of postoperative telephone follow-up contacts on recovery after benign hysterectomy : with emphasis on health-related quality of life, postoperative symptoms, and health economics
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- BackgroundThe course of a postoperative recovery is important for both patient and healthcare services. Efforts to expedite and improve recovery in a safe and cost-effective manner are therefore highly desirable from the perspective of both parties. Telephone follow-up (TFU) has been suggested as a way to improve postoperative recovery and reduce the burden of the healthcare service. This thesis intends to investigate these issues. The overall purpose of the thesis was twofold: to evaluate the effects of nurse-led TFU contacts on the recovery after benign hysterectomy, and to make a health economic analysis of TFU. The specific aims of the thesis were a) to evaluate whether TFU, particularly when combined with structured-oriented coaching, facilitated postoperative recovery in terms of health-related quality of life (HRQoL), the duration of sick leave, and the occurrence of unplanned telephone contacts (uTCs) and unplanned visits (uVs) in the postoperative period, b) to determine if the TFUs affected postoperative symptoms and the consumption of analgesics, c) to analyze whether symptoms of anxiety and depression, and low stress-coping capacity had an impact on the effect of TFU on recovery and the occurrence of uTCs and uVs, and d) to provide a health economic evaluation of the TFU from the healthcare and societal perspectives. By addressing these aims, the intention of the thesis was to contribute with important knowledge to the existing sparse body of science concerning clinical outcomes after nurse-led TFUs and their impact on recovery outcomes after benign hysterectomy. Material and methodsA four-armed, semi-blinded, randomized controlled trial was conducted at the departments of obstetrics and gynecology in five public hospitals in the southeast health region of Sweden from October 2011 to May 2017. The study comprised 487 women between 18 and 60 years old who underwent abdominal or vaginal hysterectomy for benign gynecological conditions. The treatments to be investigated were different nurse-led TFU models and consisted of four groups: Group A had no planned follow-up contact with the healthcare service after discharge (control group); Group B had one planned, structured TFU session with the research nurse (RN) on the day after discharge; Group C had a planned, structured TFU session with the RN on the day after discharge and then once weekly for six weeks; and Group D had a planned, structured, oriented coaching TFU session with the RN on the day after discharge and then once weekly for six weeks. The specific content of the TFUs in Groups B and C, as well as the oriented coaching TFU model in Group D, were outlined in the study. Demographic and clinical data relevant to the study were collected prospectively. Sick leave duration, analgesic consumption, uTC, and uV were recorded from discharge until the six-week follow-up visit with the RN. HRQoL was measured by means of the EuroQoL-5 Dimension with three levels and the Short Form Health Survey with 36 items. Psychological distress was evaluated using the Hospital Anxiety and Depression Scale and the Stress-Coping Inventory. Postoperative symptoms were assessed using the Swedish Postoperative Symptoms Questionnaire. The health economics were evaluated using a cost minimization analysis. The estimation of hospital costs was based on the principles of the Cost Per Patient (CPP) method and the prices from the CPP list for 2022 from the University Hospital in Linköping were applied. ResultsRegardless of the TFU model, women achieved baseline levels of HRQoL four weeks after surgery and no difference was seen between the intervention groups in the trajectory of recovery of HRQoL. The duration of sick leave was similar across all intervention groups, ranging from 26.8 to 28.1 days. There were no significant differences in the trajectory of the intensity of postoperative symptoms or analgesic consumption between the intervention groups. Approximately 46% of the women had uTC and 45% had uV. The oriented coaching TFU was associated with a 33% lower occurrence of uTC compared with other TFU models. Women who had uTC reported higher levels of pain intensity and sum scores of postoperative symptoms, especially when the uTC was followed by a uV. Symptoms of depression, anxiety, and low stress coping capacity did not affect the effects of the TFU models on recovery trajectories, although there were strong associations between symptoms of anxiety, depression and low stress-coping capacity and all recovery measures. In addition, uTCs were more frequent among women with anxiety. The total costs per patient more than doubled in the groups with repeated TFUs compared with the group with no TFU. The coaching TFU group had lower costs for informal care. ConclusionsNurse-led TFU after benign hysterectomy in the form used in the present study did not expedite or improve the postoperative recovery concerning HRQoL, sick leave duration postoperative symptoms, or analgesic consumption. However, nurse-led TFU with structured coaching reduced the occurrence of uTC to healthcare providers, but not uVs. Symptoms of anxiety increased the occurrence of uTC and pain seemed to be a significant cause of both uTCs and uVs, The effect of the TFU on the recovery did not seem to be affected by the psychological state of proneness to anxiety, depression, or low stress-coping capacity. Nurse-led TFUs were cost-driving for the healthcare systems and can be seen as an inefficient use of healthcare resources.
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| 4. |
- Persson, Pär, 1963-
(författare)
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On the Mode of Hysterectomy : with Emphasis on Recovery and Well‐Being
- 2009
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Hysterectomy is the surgical removal of the uterus and it is the most common major gynaecological surgical procedure worldwide. Hysterectomy is most often indicated by benign conditions such as irregular uterine bleeding with or without uterine fibroids. Several modes of hysterectomy are available each using a different surgical approach. Psychological well‐being and recovery after hysterectomy have not been carefully investigated in randomised settings. The aims of this thesis were to evaluate different modes of hysterectomy regarding postoperative psychological well‐being in long‐term follow‐up 6 and 12 months after surgery and recovery of general well‐being in short‐term up to five weeks after surgery. Additional objectives were to study the influence of the women’s stress‐coping ability on postoperative psychological well‐being and also to analyse other factors associated with postoperative psychological well‐being and recovery of general well‐being. In a randomised trial (trial 1) of 125 women who had undergone laparoscopic hysterectomy (LH) and abdominal hysterectomy (AH), no significant difference was found between the postoperative psychological well‐being of women in the two groups as indicated by four different psychometric measures up to 6 months after surgery. Neither did the day‐by‐day recovery of general well‐being differ between the women in the two hysterectomy groups, even when adjusted for consumption of analgesics. A high stress‐coping ability was strongly associated with a higher level of psychological well‐being preoperatively and a significantly faster recovery of general well‐being regardless of surgical method. In another randomised trial (trial 2) of 179 women who had undergone subtotal abdominal hysterectomy (SH) and total abdominal hysterectomy (TH), with a follow‐up time of one year, no significant difference in psychological well‐being was found between the two methods. The day‐by day recovery of general well‐being was the same in both groups. In both trial 1 and trial 2, longterm psychological well‐being improved over time during the study period regardless of the mode of hysterectomy. The occurrence of postoperative complications and a low preoperative level of psychological well‐being impair postoperative recovery significantly and prolong the duration of sick‐leave. In conclusion, the suggested benefits of the less invasive modes of hysterectomy, LH and SH, could not be proven in this study Recovery of general well‐being is associated with the woman’s stress‐coping and preoperative psychological well‐being and the studied modes of hysterectomy seem to be of less importance. This should be taken into account in preoperative counselling. Doing this will give patient and surgeon an open choice of the mode of hysterectomy to be chosen, since short‐term recovery and long‐term psychological well‐being seem to be the same in both groups in the long term.
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| 5. |
- Ramö Isgren, Anna, 1976-
(författare)
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Maternal overweight and obesity : impact on obstetric outcomes in adolescents and oxytocin in labor
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Objectives: The overall aim of this thesis was to evaluate the impact of maternal body mass index (BMI) on obstetric and neonatal outcomes in adolescents as well as on treatment with oxytocin infusion during labor regarding cumulative oxytocin dose and plasma levels of oxytocin.Material and Methods: Studies I and II were nationwide Swedish register studies including 31,386 primiparous adolescents subdivided in BMI groups and obesity classes according to early pregnancy BMI. Additionally, 178,844 low-risk normal weight adult women, called “the standard women” were included for comparison with the adolescents in the different BMI groups.Study III was an observational study conducted at seven maternity wards in the southeast region of Sweden, including 1,097 nulliparous women with spontaneous start of labor receiving oxytocin infusion during labor. The study group was subdivided according to BMI on admission to the labor ward. Cumulative oxytocin dose was registered from the start of the oxytocin infusion until the neonate was born. Study IV was an observational pilot study conducted at the maternity ward in Linköping, including 40 women in term labor receiving oxytocin infusion during the first stage of labor. The women were subdivided into obese and non-obese categories according to BMI on admission to the labor ward. Serial peripheral venous blood samples were taken during oxytocin infusion in the first stage of labor. The plasma oxytocin concentrations were analyzed with ultra performance liquid chromatography - Orbitrap tandem mass spectrometry at the Department of Chemistry Biomedical Centre, Uppsala University.Results: Compared with their normal weight counterparts and compared with the standard women, overweight and obese adolescents had increased risks for adverse pregnancy and neonatal outcomes such as preeclampsia, stillbirth, post-term pregnancy, neonates large for gestational age and neonates with low Apgar score. In labor, compared with the normal weight adolescents, the overweight and obese adolescents had a decreased chance for a normal vaginal delivery (VD), increased risk for Cesarean section (CS) and postpartum hemorrhage (PPH). However, compared with the standard women, the overweight adolescents had increased chance for a normal VD, and decreased risk for instrumental VD, CS, obstetric anal sphincter injury (OASI) and PPH in VD. The obese adolescents had an increased risk for CS but a decreased risk for instrumental VD and OASI and they had the same chance for a normal VD and no increased risk for PPH in VD.The mean cumulative oxytocin dose increased in the BMI groups (normal weight 2278 [2748] mU, overweight 3108 [3839] mU and obese 4082 [4895] mU (p<0.0001)) and the mean maximum oxytocin infusion rate during the first stage of labor was higher in the obese group compared with the overweight group of women (15.5 [9.5] mU/min vs. 13.6 [9.1] mU/min (p<0.05)). When adjusting for birth weight, epidural analgesia, and cervical dilation at the start of oxytocin infusion, the statistically significant differences were no longer seen. The obese women had increased median levels of oxytocin in plasma at an oxytocin infusion rate of 3.3 mU/min compared with the non-obese women (19.55 ng/mL [IQR 10.61; 29.06 ng/mL] vs. 6.97 ng/mL [IQR 5.55; 13.70 ng/mL], p=0.016).Conclusions: There are several adverse obstetric and neonatal outcomes associated with overweight and obesity in adolescents. It is important for clinicians to be aware of these outcomes in maternal health care. Nevertheless, overweight adolescents seemed to have better labor outcomes compared with low-risk adults, which is useful knowledge when risk-assessments are made in the labor ward.In spontaneous onset of labor, the cumulative oxytocin dose and maximum oxytocin infusion rate were higher in women with obesity compared with lower BMI groups. One explanatory factor seems to be that women with obesity received the oxytocin infusion at an earlier cervical dilatation stage. Furthermore, obese women seemed to have higher levels of oxytocin in plasma at the beginning of the oxytocin infusion. The oxytocin-oxytocin receptor complex must be further investigated to gain more knowledge on how to optimize the treatment of obese women with oxytocin infusion during labor.
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| 6. |
- Wijk, Lena, 1971-
(författare)
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Enhanced Recovery After Hysterectomy
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Objectives: To study recovery after hysterectomy under Enhanced Recovery After Surgery (ERAS) care, and in relation to different operation techniques.Materials and Methods: An observational study was conducted comparing 85 patients undergoing hysterectomy with ERAS care to 120 patients immediately before establishing ERAS. In a prospective cohort study of 121 consecutive patients undergoing hysterectomy, the outcome was compared for patients with malignant versus benign indications. The main outcome measure was length of stay (LOS). A randomised controlled trial (RCT) of 20 women scheduled for hysterectomy compared robot-assisted laparoscopic with abdominal hysterectomy in terms of the development of insulin resistance, inflammatory reactions, and clinical recovery, and examined the relation to hormonal status. All studies were conducted in 2011--2015, at the Department of Obstetrics and Gynaecology, Örebro University Hospital, Sweden.Results: Implementation of a structured ERAS protocol significantly reduced LOS compared to non-ERAS care. The effect was similar between patients with malignant and benign indications for surgery. No difference in complications was found. There was no difference in development of insulin resistance between robotic and abdominal technique, but clinical outcomes and inflammatory responses significantly favoured robot-assisted hysterectomy. Female sex hormone status was associated with the development of insulin resistance.Conclusions: Recovery after hysterectomy can be influenced. ERAS care seems to be effective and safe. Clinical outcome can also be influenced by operational technique. Hysterectomy triggers a stress reaction in both the metabolic and the inflammatory system. It remains unclear why the reduced inflammatory reaction and favourable clinical outcome in robotic surgery were not mirrored by less insulin resistance. This could not be explained by female sex hormone status.
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| 7. |
- Wedin, Madelene, 1976-
(författare)
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On lymphedema of the lower limbs after treatment of endometrial cancer : with emphasis on incidence, quality of life, risk factors, and health economy
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Objectives: The overall purpose of this study was to investigate the long-term consequences of primary surgical treatment of endometrial cancer with emphasis on lymphadenectomy, lymphedema development in the limbs, health-related quality of life, and health economy aspects. The primary objective was to assess the incidence of lymphedema both objectively and subjectively by using three different methods to determine lymphedema. Secondary objectives were to determine risk factors for lymphedema, and to analyze the impact of lymphadenectomy and lymphedema on health-related quality of life. Another secondary objective was to evaluate the hospital costs of lymphadenectomy and lymphedema one year after primary treatment of endometrial cancer.Material and methods: The study was a prospective observational longitudinal multicenter study with 15 Swedish hospitals participating between June 2014 and January 2018. Two hundred sixty-two women with presumed early stage endometrial cancer were included; 235 women completed the study. Of these, 119 were classified as having high-risk endometrial cancer and underwent surgery including lymphadenectomy, and 116 were classified as having low-risk endometrial cancer where no lymphadenectomy was performed. The women were evaluated preoperatively according to the national guidelines for endometrial cancer. The women were all monitored on four occasions: preoperatively, then four to six weeks, six months, and one year postoperatively. On all occasions, lymphedema was evaluated by means of two objective methods: systematic circumferential measurements of the lower limbs, enabling estimation of the leg volume, and by clinical grading of lymphedema of the lower limbs, and subjectively by means of the patient-reported perception of leg swelling. Health-related quality of life was evaluated using three different quality of life questionnaires. Two were generic: the SF-36 and EQ-5D-3L, and one was lymphedema-specific: the LYMQOL. Intraabdominal lymphocysts were evaluated by transvaginal ultrasound. Cost analysis of hospital costs was performed in relation to lymphadenectomy and lymphedema development.Results: The incidence of lymphedema varied between 9.5% and 29.6%, depending on the method of assessment of lymphedema. The highest incidence was found when using patient-reported swelling. The incidences of lymphedema were significantly higher in the lymphadenectomy group (14.9% - 38.1%) compared with the non-lymphadenectomy group (3.4% - 21.4%). The inter-rater agreement of lymphedema between the various methods of determining lymphedema was low. The incidence of lymphocysts was 4.3% and did not seem to pose a clinical problem. Lymphadenectomy per se did not seem to affect health-related quality of life negatively; however, lymphedema, independent of the method of assessing lymphedema, affected the lymphedema-specific quality of life significantly negatively, mainly in physical domains. Lymphadenectomy, age, and adjuvant radiation therapy were independent risk factors for lymphedema. Lymphadenectomy generated higher hospital costs, independent of the mode of surgery.Conclusions: A significant number of women develop lymphedema after lymphadenectomy in the treatment of endometrial cancer. The incidences vary, depending on the method of determining lymphedema. This inconsistency is also reflected in risk factors for lymphedema. Lymphadenectomy, increasing age, and adjuvant radiation are factors to pay attention to when planning treatment of endometrial cancer, not least because lymphedema has a negative impact on health-related quality of life. Lymphadenectomy is a cost-driving procedure and its use should be carefully evaluated in relation to its potential benefits.
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| 8. |
- Bohr Mordhorst, Louise, 1958-
(författare)
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Predictive and prognostic factors in cervical carcinomas treated with (chemo-) radiotherapy
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- A series of 131 women with cervical carcinoma FIGO stage I-IV were treated with external radiotherapy and intracavitary brachytherapy. In 47 patients (36%) concomitant chemotherapy was given. One hundred and twenty-one tumors (92%) achieved complete remission. Addition of chemotherapy increased primary cure rate to 98%. Tumor stage, tumor size, and histology were significant predictive factors for primary cure. Treatment related factors were: brachytherapy dose and interruption of irradiation.Thirty-nine recurrences (30%) were recorded. Tumor stage, histology, and concomitant chemotherapy were significant predictive factors.The 5-year cancer-specific survival rate of the complete series was 65%. Tumor size was a strong prognostic factor in multivariate analysis.Serum samples from 44 patients were analyzed. Ten candidate biomarker proteins with regard to tumor recurrences were identified.Five Hedgehog proteins were analyzed with immunohistochemistry. Residual tumor, local and distant recurrences and survival rate were associated with PTCH, SMO and GLI2. In the Wnt-β-catenin study intense staining of the membranes and nuclear staining > 5% were of significant predictive and prognostic value. Intense nuclear APC staining was associated with recurrences and cancer-specific survival rate.Conclusion: Histology, tumor size and brachytherapy dose were important clinical predictive and prognostic factors. Multiprotein analysis identified ten biomarker proteins associated with tumor recurrences. Three proteins (PTCH, SMO, and GLI2) in the Hedgehog pathway were of predictive and prognostic value. In the Wnt-β-catenin pathway intensity of β-catenin membrane staining and accumulation in the nuclei as well as nuclear APC-expression were of predictive and prognostic value.
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| 9. |
- Borendal Wodlin, Ninnie
(författare)
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Fast track abdominal hysterectomy : On the mode of anesthesia, postoperative recovery and health economics
- 2011
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Introduction: Hysterectomy is the most common major gynecological operation in the Western World and approximately 5000 benign hysterectomies are performed in Sweden every year. Consequently it is a surgical procedure that affects many women. The procedure comprises challenges concerning perioperative health care, perceived postoperative symptoms, quality of life aspects and health economics. The concept of fast track is a multimodal strategy to reduce hormonal surgical stress response and achieve an enhanced postoperative recovery and is today considered to be evidence based in relation to colorectal surgery. Spinal anesthesia, as an important part of fast track, provides benefits of extended effect on analgesia and reduced postoperative morbidity. It is reasonable to believe that employing the strategies of fast track including spinal anesthesia could also provide substantial benefits for women requiring surgical removal of the uterus.Aims: To determine whether duration of hospital stay, presence and intensity of postoperative symptoms, duration of sick leave and cost-effectiveness differ between women undergoing benign fast track abdominal hysterectomy in spinal anesthesia with intrathecal morphine (SA) and in standard general anesthesia (GA).Material & Methods: 180 women participated in this open randomized multicenter study with five participating hospitals in the southeast region of Sweden. One hundred and sixty two completed the study; 82 women were randomized to SA and 80 to GA. A fast track model comprising premedication without sedatives, intravenous fluid regulation, analgesics based on non-opioids, pre-emptive antiemetic therapy, early enteral nutrition and mobilization and standard criteria for discharge were used. End points were duration of hospital stay, use of analgesics, perceived postoperative symptoms, occurrence of postoperative complications, duration of sick leave and health economic evaluations.Results: Duration of hospital stay did not differ between the two modes of anesthesia. Vomiting and pruritus occurred significantly more often after SA. Complication rates did not differ between groups. Women with SA experienced less overall discomfort and had a reduced need for opioids postoperatively. Abdominal pain, drowsiness and fatigue occurred less often and with lower intensity among the women in the SA group. Health related quality of life improved faster and the duration of sick leave was shorter in women after SA. Total costs (hospital costs plus costs for productivity loss) were lower for the SA group. Within the first 29 days after hysterectomy the women in the SA group gained more QALYs than women in the GA group.Conclusions: The duration of hospitalisation after fast track abdominal hysterectomy was less than 50 hours and mode of anesthesia did not influence this. SA displayed considerable advantages regarding postoperative symptoms and recovery. SA was considered cost-effective in comparison with GA due to lower total costs and more QALYs gained. Our study indicates that SA should be recommended as the first choice of anesthesia in benign abdominal hysterectomy.
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| 10. |
- Karlsson, Anna, 1985-, et al.
(författare)
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The effect of tinzaparin on biomarkers in FIGO stages III-IV ovarian cancer patients undergoing neoadjuvant chemotherapy – the TABANETOC trial: study protocol for a randomized clinical multicenter trial
- 2024
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Ingår i: Acta Oncologica. - Uppsala : Medical Journals Sweden. - 0284-186X .- 1651-226X. ; 63, s. 580-585
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Tidskriftsartikel (refereegranskat)abstract
- Background: Tinzaparin, a low-molecular weight heparin (LMWH), has shown anti-neoplastic properties in animal models and in in vitro studies of human cancer cell lines. The reduction of CA-125 levels during neoadjuvant chemotherapy (NACT) in patients with epithelial ovarian cancer (EOC) co-varies with the prognosis; the larger the decrease in CA-125, the better the prognosis.Purpose: This study aims to evaluate the potential anti-neoplastic effects of tinzaparin by investigating changes in serum CA-125 levels in advanced EOC patients who receive NACT.Material and methods: This is an open randomized multicenter pilot trial. Forty patients with EOC selected to receive NACT will be randomized 1:1 to receive daily addition of tinzaparin or no tinzaparin. The processing and treatment of the patients will otherwise follow the recommendations in the Swedish National Guidelines for Ovarian Cancer. Before every cycle of chemotherapy, preoperatively, and 3 weeks after the last cycle of chemotherapy, a panel of biomarkers, including CA-125, will be measured.Patients: Inclusion criteria are women aged 18 years or older, World Health Organization performance status 0–1, histologically confirmed high-grade serous, endometrioid or clear cell EOC, International Federation of Gynecology and Obstetrics (FIGO) stages III-IV. In addition, a CA-125 level of ≥ 250 kIE/L at diagnosis. Exclusion criteria are contraindications to LMWH, ongoing or recent treatment with unfractionated heparin, LMWH, warfarin or non-vitamin K antagonist oral anticoagulants.Interpretation: This study will make an important contribution to the knowledge of the anti-neoplastic effects of tinzaparin in EOC patients and may thus guide the planning of a future study on the impact of tinzaparin on survival in EOC.
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