الفهرس 
Acknowledgement
Endometrial Cancer Epidemiology and PathologyOnly 14 pages are availabe for public view
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Abstract
Endometrial cancer is the sixth most common cancer in women worldwide. With the increasing acceptance for minimal invasive approaches for management of endometrial cancer, the adoption of the robotic platform is competing to be the front runner. The robotic surgical platform has enabled increasingly complex minimally invasive pelvic surgery in the obese.
While some studies have reported successful outcomes with robotic surgery in women with high body mass index, the anesthetic challenges of maintaining pneumoperitoneum and steep Trendelenburg in this population remain problematic and anesthetic intolerance still limits the universal application of this technology in the obese population. Anesthetic intolerance is the main factor responsible for conversion to laparotomy in such population. Visceral adipose, rather than BMI, was more closely associated with risk for early conversions.
Various techniques utilizing CT, ultrasound and magnetic resonance imaging are now emerging that can directly quantify adipose distribution and recent studies suggest the potential for their direct clinical application.
Failure of application of a standard grading system for surgical complications will lead to non-effective interpretation of surgical outcomes & eventually bias in evaluation of surgical approaches. The Clavien-Dindo classification is a valid & applicable system for surgical complications grading & is used worldwide.
Since the primary treatment of endometrial cancer is surgical & as utilization of the robotic platform expands to an increasing number of surgeons for cases of increasing technical complexity, there is a great need to better understand the factors behind its high cost.
The thesis includes two clinical studies of robotic management of endometrial cancer:
The first clinical study aims to validate a method using CT morphometrics that best predicts endometrial cancer patients at greatest risk for intraoperative physiological intolerance to robotic surgery.
We performed a retrospective chart review of 59 endometrial cancer patients at University Hospitals Cleveland Medical Center after institutional review board approval. The patients underwent robotic hysterectomy, salpingo-oophorectomy and associated retroperitoneal lymphadenectomy between April 2008 and May 2014 and also underwent perioperative CT scan within 1 year of the surgery. Several CT slices were used at each measurement level for adipose tissue volume quantification and reconstruction to yield a 5-mm-thick final slice. Seven final measurements were estimated: mid-waist circumference (cm), mid-waist VFV (cm3), midwaist SFV (cm3), L2-L3 VFV (cm3), L2-L3 SFV (cm3), L4-L5 VFV (cm3), and L4-L5 SFV (cm3).
The median age was 68 years and the average BMI was 34 kg/m2. 44.1% of patients had history of abdominal or pelvic surgery. 49.2% were ASA class III. Nearly70% had history of cardiac disease. Six patients were converted to laparotomy. The mean VFV value at L4-L5 was higher than at L2-L3 or mid-waist. In contrast, mean SFV was higher at mid-waist than at L4-L5 or L2-L3. On multivariate analysis and after adjustment for age, ethnicity, diabetes, heart disease, pulmonary disease, smoking, obstructive sleep apnea, ASA classification, and duration of anesthesia, the CT morphometric measurements were all significant independent predictors of PAP (average and maximum) and Pplat (average and maximum). L2-L3 VFV was the best predictor among the CT morphometrics for average PAP (β = 0.4, t = 3.33, p = 0.002), maximum PAP (β = 0.49, t = 4.1, p < 0.001), average Pplat (β = 0.54, t = 4.83, p < 0.001), and maximum Pplat (β = 0.57, t = 5.12, p < 0.001).
We concluded that the novel CT-quantified morphometric technique used in this study can help identify obese patients likely to manifest physiological intolerance to robotic pelvic surgery. Of the measures analyzed here, VFV at L2-L3 best predicts the highest intraoperative airway pressures in obese patients.
The second clinical study aims to estimate the risk of intraoperative and postoperative complications of robotic-assisted surgery for the management of endometrial cancer utilizing both the modified C-D and JCOG classification systems and to identify risk factors responsible for those complications and describe their impact on cost.
We conducted a retrospective chart review of 156 endometrial cancer patients who were managed by robotic surgery from April 2008 to May 2014 at University Hospitals Cleveland Medical Center after institutional review board approval was obtained. Postoperative complications were catalogued utilizing the modified Clavien-Dindo classification and the Japan Clinical Oncology group postoperative complications criteria (JCOG PC criteria). We utilized hospital charges that were provided by the institution’s financial department. For this study, we used the total direct charges (adapted from variable and fixed direct costs).
Mean (SD) age of the cohort population was 65 (11) years. The majority of patients were Caucasians (92%) with mean body mass index (BMI) 35.7 (8.5) kg/m2. Thirty one percent had 3 or more prior births. Almost half the patients (45.5%) had previous abdominal or pelvic surgeries. Medical comorbidities were common in this population. ASA class III or higher was highly prevalent (60.8%) of the study population. The majority of patients had low risk pathologic features.
Intraoperative complications occurred in 8 patients (5.1%). Conversion to laparotomy occurred in 20 patients (12.8%). Postoperative complications occurred in 44 patients (28.2%) with (8.3%) of them experiencing serious complications (grade 3 or more) according to the modified C-D classification. Using the (JCOG PC) criteria, 16 (36.36%) complications were labeled under the category {others (no AE term)}. Inter-observer variability in assigning complication grading was quite low for both classification systems. One patient necessitated re-exploration twice and one patient died.
In multivariate regression, adhesiolysis, FIGO stage, estimated blood loss, omentectomy and BMI were significant predictors for conversion to laparotomy after adjusting for the other variables. As for postoperative complications, conversion to laparotomy and increased parity independently predicted a postoperative complication while having diabetes or high preoperative hemoglobin decreased the odds of experiencing a postoperative complication after adjusting for other variables. While for a Clavien-Dindo grade ≥ 3 complication, conversion to laparotomy, increased parity and operative time predicted it after adjusting for the other variables.
Analyzing the overall charges demonstrated that experiencing an intraoperative complication or conversion to laparotomy significantly increased the total costs. While this was not the case as having a postoperative complication or having a Clavien-Dindo grade 3 or more complication. Experiencing an intraoperative complication will increase the total costs by 4987.73 $ and every minute increase in the operative time will increase the total costs by 16.14 $.
We concluded the modified Clavien-Dindo classification is a valid system for reporting postoperative complications and should be used widely in gynecologic oncology studies. The JCOG PC criteria need modifications to fit gynecologic complications. Conversion to laparotomy and intraoperative complications pose substantial extra charges on the surgery cost. Careful adhesiolysis and omentectomy especially in morbidly obese patients will decrease the incidence of conversions and subsequently intraoperative and postoperative complications with their associated costs. Increased parity is a non-modifiable risk factor for postoperative and grave complications, hence proper preoperative planning for those patients should be warranted. With the optimal surgical approach sought for endometrial cancer management, cost minimization strategies must be taken into account.