Salpingectomy for Sterilization

Transcription

1 Salpingectomy for Sterilization Change in Practice in a Large Integrated Health Care System Journal Club November 15, 2017 Blaine Campbell, DO

2 Salpingectomy for Sterilization: Change in Practice in a Large Integrated Health Care System, C. Bethan Powell MD et all Obstetrics and Gynecology, 130: November 2017 From the Kaiser Permanente Northern California Gynecologic Cancer Program San Francisco, Kaiser Permanente Northern California Division of Research Oakland, Kaiser Permanente OBGYN Residency Program San Francisco, and the Division of Gynecologic Oncology at the University of Virginia, Charlottesville, VA

3 Background Evidence supports the fallopian tube as the potential site of origin for some ovarian cancers In 2013, the Kaiser Permanente Northern California group published a policy statement recommending salpingectomies for surgical tubal sterilization at the time of hysterectomy Society of Gynecologic Oncologists (SGO) and American College of Obstetricians and Gynecologists (ACOG)

4 By performing salpingectomy in operation in which the fallopian tubes could be removed the risk of ovarian cancer may be further reduced. Randomized controlled trials are needed to support the validity of this approach. Other than a significant increase in operative time no significant differences in operative times or complication rates for salpingectomy have been identified. For women at population risk (average) for ovarian cancer, salpingectomy should be considered (after completion of childbearing) at the time of hysterectomy, in lieu of tubal ligation, and also at the time of other pelvic surgery. The pathologic specimen processing in low risk women should include representative sections of the tube, any suspicious lesions, and entire sectioning of the fimbriae.

5 Materials and Methods Retrospective cohort study, including 10,741 total cases PRIMARY OBJECTIVE Evaluate utilization of salpingectomy for tubal sterilization in the cesarean, postpartum, and interval settings from SECONDARY OUTCOMES Blood loss Operating time Length of stay Readmission rates within 30 days ER visits within 7 days

6 Materials and Methods INCLUSION CRITERIA Age >18 years old Surgical database ( tubal occlusion, ligation, fulguration, salpingectomy, cesarean ) EXCLUSION CRITERIA Hysterectomy Procedure involving oophrectomy Diagnosis of ectopic pregnancy Personal history of ovarian cancer, BRCA1/BRCA2, or Lynch mutation

7 Materials and Methods Salpingectomy Occlusion procedures: clips, rings, fulguration, partial salpingectomy, and cutting/suture interruption as previously described by Westberg et al Most were bipolar, monopolar, or suture Other information collected: Age, race, parity, neighborhood poverty level, BMI Medical center surgery was performed, OR time, postop stay, EBL Readmissions and ER visits used as markers of complications

8 Materials and Methods Peripartum: performed at time of cesarean and within 3 days of vaginal delivery Cesarean and postpartum Interval: all other procedures Concurrent procedures: performed with any other major procedure (ex: cholecystectomy, ovarian cystectomy, appendectomy); minor procedures not included (cervical biopsies or EMB) Information broken down in 1-year intervals X 2 and Fisher exact tests

9 Results PRIMARY OUTCOME: Evaluate utilization of salpingectomy for tubal sterilization in the cesarean, postpartum, and interval settings from Increase in utilization of salpingectomy as method of sterilization for interval sterilization but not for peripartum period

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11 Results SECONDARY OUTCOMES: (salpingectomy vs tubal occlusion) Blood loss Cesarean: 700ml vs 660ml (P = 0.24) Postpartum: 250ml vs 200ml (P = 0.04). Interval: 5ml for both (P = 0.65) Operating time Cesarean: 9.5 minutes longer (P = <0.001) Postpartum: 17 minutes longer (P = 0.003) Interval: 3 minutes longer (P = <0.001)

12 Results SECONDARY OUTCOMES: (salpingectomy vs tubal occlusion) Length of stay no statistically significant change Readmission rates within 30 days no statistically significant change ER visits within 7 days no statistically significant change

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14 Discussion ACOGs recommendation, SGO recommendation Practice similar to WMC prior to release of material Most tubals were occlusive by bipolar, monopolar, and suture Meticulous about data to ensure numbers were correct for each procedure Coding of procedures and checking pathology reports Considering another major procedure at same time as sterilization Distinguishing between procedure types Numbers Broke down data to cesarean, postpartum, and interval tubals for interpretation and utilization into one s own practice

15 Questions and Comments

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