Impact of surgeon volume - PowerPoint Presentation

Slide1

Impact of

surgeon volume on myomectomy route: A multicenter review from the Minimally Invasive Gynecologic Surgery Fellows’ Pelvic Research Network

Patricia J. Mattingly

,

MD

Stacey

Scheib

, MD

Kelly Wright, MD Slide2

Disclosures

I have no disclosures. Slide3

Background

Uterine leiomyomas are the most common benign tumors of the female genital tract and are clinically evident in approximately 25% of women of reproductive age.1,2 In

2010, approximately 37,134 myomectomies were performed in the United

States.

3

The

annual number of myomectomies performed in the United States is projected to increase to 49,154 by the year

2050.

3

Slide4

Background

Compared to abdominal myomectomy, laparoscopic myomectomy less blood loss, fewer blood transfusions, less postoperative pain, decreased febrile morbidity, shorter hospital stays and a faster recovery. 4,5,6

N

o

significant difference in risk of fibroid recurrence, major complications and pregnancy and perinatal

outcomes.

4,5,6

Laparoscopic myomectomy requires advanced laparoscopic skills that not all gynecologic surgeons possess.

5,7,8,9Slide5

Background

Surgical outcomes have been shown to be affected by surgeon volume.10,11,12Surgeon’s hysterectomy volume has been shown to affect surgical approach.11

Laparoscopic

hysterectomy complication rates have been directly correlated with surgeon

volume.

10

There

is limited data that examines the association between myomectomy outcomes and surgeon volume and training.

Slide6

Objectives

Primary ObjectiveDetermine if there is an association between myomectomy route and surgeon volume. Slide7

Objectives

Secondary Objectives:Determine if there is an association between myomectomy route and training in a fellowship in minimally invasive gynecologic surgery. Determine

if there is an association between myomectomy perioperative outcomes and surgeon volume

and training.

Slide8

Objectives

HypothesisA higher proportion of myomectomies are completed laparoscopically when performed by a high-volume gynecologic surgeon or a gynecologic surgeon who has completed a fellowship in minimally invasive gynecologic surgery. Slide9

Methods

Design: Retrospective cohort study Inclusion: women 18

years or older

abdominal

, laparoscopic or robot-assisted laparoscopic myomectomy for benign indications

July

1 2016 – June 30

2017

Exclusion:

e

mergency surgery

w

omen younger than 18 years Slide10

Methods

Primary outcome:rates of abdominal and laparoscopic myomectomy Secondary outcomes: operative time

r

oute of tissue extraction

i

ntraoperative complication

EBL, blood transfusion

c

onversion rate

length of hospital stay

pathology diagnosis & size (g)Slide11

Methods

Surgeon characteristics major gynecologic surgeries: hysterectomy, myomectomy, endometriosis Fellowship training operative time, r

oute of tissue extraction, intraoperative complication, EBL, blood transfusion, conversion rate, length of hospital stay, pathology diagnosis & size (g)

Hospital

characteristics

Location, region, size, teaching status Slide12

Methods

Electronic medical records used to myomectomy by CPT code Sample size: CI 95%, 80% power

Assume the

proportion of laparoscopic myomectomies by

high-volume surgeons is

50%

vs 25% for low-volume surgeons

the

same size needed is

55Slide13

Methods

Statistical analysis Demographic characteristics of the two groups will be analyzed using unpaired Student t tests for continuous variables and X2 or Fisher’s exact test for categorical variables.

Results will be expressed as unadjusted relative risks (RRs) with 95% confidence intervals (CIs). Slide14

Timeline & Budget

Multicenter Redcap database Recruit sites Obtain IRB approval Retrospective chart review

18 months

Budget: $3,000 Slide15

Thank you

Items for DiscussionSurgeon volume vs fellowship training Define high-volume surgeon Scope of data collection Slide16

References

Borah BJ, Nicholson WK, Bradley L, et al. The impact of uterine leiomyomas: a national survey of affected women. Am J Obstet Gynecol 2013;209:319.e1-20. Stewart EA. Uterine fibroids. Lancet. 2001;357:293–298

Wechter

ME, Stewart EA, Myers ER, Kho RM, Wu JM. Leiomyoma-related hospitalization and surgery: prevalence and predicted growth based on population trends. American Journal of Obstetrics and Gynecology. 2011;205(5). doi:10.1016/j.ajog.2011.07.008

.

Bhave

Chittawar

P, 

Franik

S, 

Pouwer

AW, Farquhar C. Minimally invasive surgical techniques versus open myomectomy for uterine fibroids. Cochrane Database of Systematic Reviews 2014, Issue 10. Art. No.: CD004638.

Jin

C, Hu Y, Chen X-C, et al. Laparoscopic versus open myomectomy—A meta-analysis of randomized controlled trials. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2009;145(1):14-21. doi:10.1016/j.ejogrb.2009.03.009.

Hurst

B, Matthews M,

Marshburn

P. Laparoscopic myomectomy for symptomatic uterine

myomas

. Fertility and Sterility. 2005;83(1):1-23. doi:10.1016/j.fertnstert.2004.09.011

.Slide17

References

Mikhail E, Scott L, Miladinovic B, Imudia AN, Hart S. Association between Fellowship Training, Surgical Volume, and Laparoscopic Suturing Techniques among Members of the American Association of Gynecologic Laparoscopists. Minimally Invasive Surgery. 2016;2016:1-6. doi:10.1155/2016/5459147.

Einarsson

J, Young A,

Tsien

L,

Sangi-Haghpeykar

H. Perceived Proficiency in Endoscopic Techniques Among Senior Obstetrics and Gynecology Residents. 

The Journal of the American Association of Gynecologic Laparoscopists

. 2002;9(2):158-164. doi:10.1016/s1074-3804(05)60124-7

.

Magrina

JF.

Isnt

It Time to Separate the O From the G? 

Journal of Minimally Invasive Gynecology

. 2014;21(4):501-503. doi:10.1016/j.jmig.2014.01.022.

Wallenstein, Michelle R., et al. “Effect of Surgical Volume on Outcomes for Laparoscopic Hysterectomy for Benign Indications.” 

Obstetrics & Gynecology

, vol. 119, no. 4, 2012, pp. 709–716., doi:10.1097/aog.0b013e318248f7a8

.

Boyd LR,

Novetsky

AP, Curtin JP. Effect of Surgical Volume on Route of Hysterectomy and Short-Term Morbidity. 

Obstetrics & Gynecology

. 2010;116(4):909-915. doi:10.1097/aog.0b013e3181f395d9.

Vree

,

Florentien

E. M

. The

Impact of Surgeon Volume on Perioperative Outcomes in

Hysterectomy.”

1

Jan. 1970,

archive.org

/details/pubmed-PMC4035626.