Fast-track surgery in gynaecology and gynaecologic oncology: a review of a rolling clinical audit

Jonathan Carter, Jonathan Carter

Abstract

Clinical audit is the process by which clinicians are able to demonstrate to themselves, their patients, hospital administrators, and healthcare financial providers the outcome and safety of their clinical practice. It is a process by which the public can be assured of safety and outcomes. A fast-track surgery program was initiated in January 2008, and this paper represents a rolling clinical audit of the outcomes of that program until the end of June 2012. Three hundred and eighty-nine patients underwent fast track surgical management after having a laparotomy for suspected or confirmed gynaecological cancer. There were no exclusions and the data presented represents the practice and outcomes of all patients referred to a single gynaecological oncologist. The majority of patients were deemed to have complex surgical procedures performed usually through a vertical midline incision. One third of patients had a nonzero performance status, median weight was 68 kilograms, and median BMI was 26.5 with 31% being classified as obese. Median operating time was 2.25 hours, and the median estimated blood loss was 175 mL. Overall the median length of stay (LOS) was 3 days with 95% of patients tolerating early oral feeding. Four percent of patients required readmission, and 0.5% were required to return to the operating room. Whilst the wound infection rate was 2.6%, there were no ureteric, bowel or neurovascular injuries. Overall there were 2 bladder injuries (0.5%), and the incidence of venous thromboembolism was 1%. Subset analysis was also undertaken. Whilst a number of variables were associated with reduced LOS, on multivariate analysis, benign pathology, shorter operating time, and the ability to tolerate early oral feeding were found to be significant. The data and experience presented is the largest and most extensive reported in the literature relating to fast-track surgery in gynaecology and gynaecologic oncology. The public can be reassured of the safety and improved outcomes that can be achieved after the introduction of such a program.

Figures

Figure 1
Figure 1
Elements of a fast-track surgery program.
Figure 2
Figure 2
Fast-track surgery program.

References

    1. Scally G, Donaldson LJ. Clinical governance and the drive for quality improvement in the new NHS in England. British Medical Journal. 1998;317(7150):61–65.
    1. RACS. A Guide By the Royal Australian College of Surgeons. Surgical Audit and Peer Review. Melbourne, Australia: Royal Australian College of Surgeons; 2008.
    1. Grover FL, Shroyer ALW, Hammermeister K, et al. A decade’s experience with quality improvement in cardiac surgery using the veterans affairs and Society of Thoracic Surgeons national databases. Annals of Surgery. 2001;234(4):464–474.
    1. Kehlet H. Fast-track colorectal surgery. The Lancet. 2008;371(9615):791–793.
    1. Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. American Journal of Surgery. 2002;183(6):630–641.
    1. Kehlet H. Principles of fast track surgery: multimodal perioperative therapy programme. Chirurg. 2009;80(8):687–689.
    1. Carli F, Charlebois P, Baldini G, Cachero O, Stein B. An integrated multidisciplinary approach to implementation of a fast-track program for laparoscopic colorectal surgery. Canadian Journal of Anesthesia. 2009;56(11):837–842.
    1. Varadhan KK, Lobo DN, Ljungqvist O. Enhanced recovery after surgery: the future of improving surgical care. Critical Care Clinics. 2010;26(3):527–547.
    1. Lassen K, Soop M, Nygren J, et al. Consensus review of optimal perioperative care in colorectal surgery: enhanced Recovery after Surgery (ERAS) Group recommendations. Archives of Surgery. 2009;144(10):961–969.
    1. Varadhan K, Neal K, Dejong CHC, Fearon KCH, Lobo DN. The enhanced recovery after surgery (ERAS) pathway for patients undergoing major elective open colorectal surgery: a meta-analysis of randomised controlled trials. Clinical Nutrition. 2010;29(4):434–440.
    1. Carter J, Philp S, Arora A. Fast track gynaecologic surgery in the overweight and obese patient. International Journal of Clinical Medicine. 2010;1(2):64–69.
    1. Carter J, Philp S, Arora V. Poster presentation. Extended experience with an enhanced surgical recovery program. Proceedings of the 13th Biennial Meeting of the International Gynecologic Cancer Society; 2010; Prague, Czech Republic. European Union;
    1. Carter J, Philp S, Arora V. Discharge on postop day 2 after major gynaecological surgery. Is it possible?. Oral Presentation 25th Annual Scientific Meeting Australian Society of Gynaecological Oncologists; March 2010; Bunker Bay, Western Australia.
    1. Carter J, Szabo R, Sim WW, et al. Fast track surgery in gynaecological oncology. A clinical audit. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2010;50(2):159–163.
    1. Carter J, Philp S. Assessing outcomes after fast track surgical management of corpus cancer. Open Journal of Obstetrics and Gynecology. 2011;1(3):139–143.
    1. Carter J, Philp S. Development and Extended Experience with a Fast Track Surgery Program. Queenstown, New Zealand: Australian Society of Gynaecological Oncologists Annual Scientifc Meeting Millbrook Resort; 2011.
    1. Carter J, Philp S, Arora V. Early discharge after major gynaecological surgery: advantages of fast track surgery. Open Journal of Obstetrics and Gyaecology. 2011;1(1):1–5.
    1. Lv D, Wang X, Shi G. Perioperative enhanced recovery programmes for gynaecological cancer patients. Cochrane Database of Systematic Reviews. 2010;6:p. CD008239.
    1. Cameron A. Brief Review: Fast-Track Surgery and Enhanced Recovery After Surgery (ERAS) Programs. East Melbourne, Australia: Australian Safety and Efficacy Register of New Interventional Procedures-Surgical (ASERNIPS-S); 2009.
    1. Ramírez JM, Blasco JA, Roig J, et al. Enhanced recovery in colorectal surgery: a multicentre study. BMC Surgery. 2011;11:p. 9.
    1. Basse L, Jakobsen DH, Bardram L, et al. Functional recovery after open versus laparoscopic colonic resection: a randomized, blinded study. Annals of Surgery. 2005;241(3):416–423.
    1. Katkhouda N, Mason RJ, Towfigh S, et al. Laparoscopic versus open appendectomy: a prospective randomized double-blind study. Annals of Surgery. 2005;242(3):439–450.
    1. Ogonda L, Wilson R, Archbold P, et al. A minimal-incision technique in total hip arthroplasty does not improve early postoperative outcomes: a prospective, randomized, controlled trial. Journal of Bone and Joint Surgery A. 2005;87(4):701–710.
    1. Majeed AW, Troy G, Nicholl JP, et al. Randomised, prospective, single-blind comparison of laparoscopic versus small-incision cholecystectomy. The Lancet. 1996;347(9007):989–994.
    1. McDonnell JG, O’Donnell B, Curley G, Heffernan A, Power C, Laffey JG. The analgesic efficacy of transversus abdominis plane block after abdominal surgery: a prospective randomized controlled trial. Anesthesia and Analgesia. 2007;104(1):193–197.
    1. Arora V, Philp S, Nattress K, et al. Patient satisfaction with inpatient care provided by the Sydney Gynecological Oncology Group. Patient Related Outcome Measures. 2010;1:179–184.
    1. Niranjan N, Bolton T, Berry C. Enhanced recovery after surgery-current trends in perioperative care. Update in Anaesthesia. 2010;26(1):18–23.
    1. Callesen T, Klarskov B, Bech K, Kehlet H. Short convalescence after inguinal herniorrhaphy with standardised recommendations: duration and reasons for delayed return to work. European Journal of Surgery. 1999;165(3):236–241.
    1. Egbert LD, Battit GE, Welch CE, Bartlett MK. Reduction of postoperative pain by encouragement and instruction of patients. A study of doctor-patient rapport. The New England Journal of Medicine. 1964;270:825–827.
    1. Dierking G, Duedahl TH, Rasmussen ML, et al. Effects of gabapentin on postoperative morphine consumption and pain after abdominal hysterectomy: a randomized, double-blind trial. Acta Anaesthesiologica Scandinavica. 2004;48(3):322–327.
    1. Turan A, Karamanlioğlu B, Memiş D, Usar P, Pamukçu Z, Türe M. The analgesic effects of gabapentin after total abdominal hysterectomy. Anesthesia and Analgesia. 2004;98(5):1370–1373.
    1. Gilron I, Orr E, Tu D. A placebo-controlled randomized clinical trial of perioperative administration of gabapentin, rofecoxib and their combination for spontaneous and movement-evoked pain after abdominal hysterectomy. Pain. 2005;113:191–200.
    1. Fassoulaki A, Stamatakis E, Petropoulos G, Siafaka I, Hassiakos D, Sarantopoulos C. Gabapentin attenuates late but not acute pain after abdominal hysterectomy. European Journal of Anaesthesiology. 2006;23(2):136–141.
    1. Sen H, Sizlan A, Yanarates O, et al. A comparison of gabapentin and ketamine in acute and chronic pain after hysterectomy. Anesthesia and Analgesia. 2009;109(5):1645–1650.
    1. Ajori L, Nazari L, Mazloomfard MM, Amiri Z. Effects of gabapentin on postoperative pain, nausea and vomiting after abdominal hysterectomy: a double blind randomized clinical trial. Archives of Gynecology and Obstetrics. 2011:1–6.
    1. Radhakrishnan M, Bithal PK, Chaturvedi A. Effect of preemptive gabapentin on postoperative pain relief and morphine consumption following lumbar laminectomy and discectomy: a randomized, double-blinded, placebo-controlled study. Journal of Neurosurgical Anesthesiology. 2005;17(3):125–128.
    1. Ong CKS, Seymour RA, Lirk P, Merry AF. Combining paracetamol (acetaminophen) with nonsteroidal antiinflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain. Anesthesia and Analgesia. 2010;110(4):1170–1179.
    1. Maund E, McDaid C, Rice S, Wright K, Jenkins B, Woolacott N. Paracetamol and selective and non-selective non-steroidal anti-inflammatory drugs for the reduction in morphine-related side-effects after major surgery: a systematic review. British Journal of Anaesthesia. 2011;106(3):292–297.
    1. Ng A, Smith G, Davidson AC. Analgesic effects of parecoxib following total abdominal hysterectomy. British Journal of Anaesthesia. 2003;90(6):746–749.
    1. Bikhazi GB, Snabes MC, Bajwa ZH, et al. A clinical trial demonstrates the analgesic activity of intravenous parecoxib sodium compared with ketorolac or morphine after gynecologic surgery with laparotomy. American Journal of Obstetrics and Gynecology. 2004;191(4):1183–1191.
    1. American Society of Anesthesiologists Committee. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters. Anesthesiology. 2011;114(3):495–511.
    1. Noblett SE, Watson DS, Huong H, Davison B, Hainsworth PJ, Horgan AF. Pre-operative oral carbohydrate loading in colorectal surgery: a randomized controlled trial. Colorectal Disease. 2006;8(7):563–569.
    1. Zeinali F, Stulberg JJ, Delaney CP. Pharmacological management of postoperative ileus. Canadian Journal of Surgery. 2009;52(2):153–157.
    1. Wilson JP. Postoperative motility of the large intestine in man. Gut. 1975;16(9):689–692.
    1. Woods JH, Erickson LW, Condon RE. Postoperative ileus: a colonic problem? Surgery. 1978;84(4):527–533.
    1. Fanning J, Valea FA. Perioperative bowel management for gynecologic surgery. American Journal of Obstetrics and Gynecology. 2011
    1. Güenaga KK, Matos D, Wille-Jørgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database of Systematic Reviews. 2009;(1):p. CD001544.
    1. Agnelli G, Bolis G, Capussotti L, et al. A clinical outcome-based prospective study on venous thromboembolism after cancer surgery: the RISTOS project. Annals of Surgery. 2006;243(1):89–95.
    1. Sweetland S, Green J, Liu B, et al. Duration and magnitude of the postoperative risk of venous thromboembolism in middle aged women: prospective cohort study. British Medical Journal. 2009;339:p. b4583.
    1. White RH, Zhou H, Romano PS. Incidence of symptomatic venous thromboembolism after different elective or urgent surgical procedures. Thrombosis and Haemostasis. 2003;90(3):446–455.
    1. Peedicayil A, Weaver A, Li X, Carey E, Cliby W, Mariani A. Incidence and timing of venous thromboembolism after surgery for gynecological cancer. Gynecologic Oncology. 2011;121(1):64–69.
    1. Phillips SM, Gallagher M, Buchan H. Change page: use graduated compression stockings postoperatively to prevent deep vein thrombosis. British Medical Journal. 2008;336(7650):943–944.
    1. NHMRC. Clinical Practice Guidelines For the Prevention of Venous Thromboembolism (Deep Vein Thrombosis and Pulmonary Embolism) in Patients Admitted to Australian Hospitals. Canberra, Australia: National Health and Medical Research Council:; 2009.
    1. Bergqvist D, Agnelli G, Cohen AT, et al. Duration of prophylaxis against venous thromboembolism with enoxaparin after surgery for cancer. New England Journal of Medicine. 2002;346(13):975–980.
    1. Rasmussen MS, Jørgensen LN, Wille-Jørgensen P. Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery. Cochrane Database of Systematic Reviews. 2009;(1):p. CD004318.
    1. Fotopoulou C, Dubois A, Karavas AN, et al. Incidence of venous thromboembolism in patients with ovarian cancer undergoing platinum/paclitaxel-containing first-line chemotherapy: an exploratory analysis by the Arbeitsgemeinschaft Gynaekologische Onkologie Ovarian Cancer Study Group. Journal of Clinical Oncology. 2008;26(16):2683–2689.
    1. Fearon KCH, Ljungqvist O, Von Meyenfeldt M, et al. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clinical Nutrition. 2005;24(3):466–477.
    1. Andtbacka RHI, Babiera G, Singletary SE, et al. Incidence and prevention of venous thromboembolism in patients undergoing breast cancer surgery and treated accordinq to clinical pathways. Annals of Surgery. 2006;243(1):96–101.
    1. Power I, Barratt S. Analgesic agents for the postoperative period: nonopioids. Surgical Clinics of North America. 1999;79(2):275–295.
    1. Wodlin NB, Nilsson L, Kjã˜lhede P. Health-related quality of life and postoperative recovery in fast-track hysterectomy. Acta Obstetricia et Gynecologica Scandinavica. 2011;90(4):362–368.
    1. Pather S, Loadsman JA, Gopalan PD, Rao A, Philp S, Carter J. The role of transversus abdominis plane blocks in women undergoing total laparoscopic hysterectomy: a retrospective review. Australian and New Zealand Journal of Obstetrics and Gynaecolog. 2011;51(6):544–547.
    1. Abdallah FW, Chan VW, Brull R. Transversus abdominis plane block: a systematic review. Regional Anesthesia and Pain Medicine. 2012;37(2):193–209.
    1. Johns N, O’Neill S, Ventham NT, Barron F, Brady RR, Daniel T. Clinical effectiveness of transversus abdominis plane (TAP) block in abdominal surgery: a systematic review and meta-analysis. Colorectal Disease. 2012;14(10):635–642.
    1. Kroon UB, Radstrom M, Hjelthe C, Dahlin C, Kroon L. Fast-track hysterectomy: a randomised, controlled study. European Journal of Obstetrics Gynecology and Reproductive Biology. 2010;151(2):203–207.
    1. Acheson N, Crawford R. The impact of mode of anaesthesia on postoperative recovery from fast-track abdominal hysterectomy: a randomised clinical trial. An International Journal of Obstetrics and Gynaecology. 2011;118(3):271–273.
    1. Wodlin NB, Nilsson L, Kjølhede P. The impact of mode of anaesthesia on postoperative recovery from fast-track abdominal hysterectomy: a randomised clinical trial. An International Journal of Obstetrics and Gynaecology. 2011;118(3):299–308.
    1. Carli F, Kehlet H, Baldini G, et al. Evidence basis for regional anesthesia in multidisciplinary fast-track surgical care pathways. Regional Anesthesia and Pain Medicine. 2011;36(1):63–72.
    1. Cheatham ML, Chapman WC, Key SP, et al. A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy. Annals of Surgery. 1995;221(5):469–478.
    1. Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after abdominal surgery. Cochrane Database of Systematic Reviews. 2005;(1):p. CD004929.
    1. Baldini G, Carli F. Anesthetic and adjunctive drugs for fast-track surgery. Current Drug Targets. 2009;10(8):667–686.
    1. MacKay G, Fearon K, McConnachie A, Serpell MG, Molloy RG, O’Dwyer PJ. Randomized clinical trial of the effect of postoperative intravenous fluid restriction on recovery after elective colorectal surgery. British Journal of Surgery. 2006;93(12):1469–1474.
    1. Brandstrup B, Tønnesen H, Beier-Holgersen R, et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens-a randomized assessor-blinded multicenter trial. Annals of Surgery. 2003;238(5):641–648.
    1. Bundgaard-Nielsen M, Secher NH, Kehlet H. ‘Liberal’ vs. ‘restrictive’ perioperative fluid therapy-a critical assessment of the evidence: review Article. Acta Anaesthesiologica Scandinavica. 2009;53(7):843–851.
    1. Thompson EGE, Gower ST, Beilby DS, et al. Enhanced recovery after surgery program for elective abdominal surgery at three Victorian hospitals. Anaesth Intensive Care. 2012;40(3):450–459.
    1. Patel GN, Rammos CK, Patel JV, Estes NC. Further reduction of hospital stay for laparoscopic colon resection by modifications of the fast-track care plan. American Journal of Surgery. 2010;199(3):391–395.
    1. Lopes ADB, Hall JR, Monaghan JM. Drainage following radical hysterectomy and pelvic lymphadenectomy: dogma or need? Obstetrics and Gynecology. 1995;86(6):960–963.
    1. Karliczek A, Jesus EC, Matos D, Castro AA, Atallah AN, Wiggers T. Drainage or nondrainage in elective colorectal anastomosis: a systematic review and meta-analysis. Colorectal Disease. 2006;8(4):259–265.
    1. Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. New England Journal of Medicine. 1996;334(19):1209–1215.
    1. Lenhardt R, Marker E, Goll V, et al. Mild intraoperative hypothermia prolongs postanesthetic recovery. Anesthesiology. 1997;87(6):1318–1323.
    1. Ayalon O, Liu S, Flics S, Cahill J, Juliano K, Cornell CN. A multimodal clinical pathway can reduce length of stay after total knee arthroplasty. HSS Journal. 2011;7(1):9–15.
    1. Schwarzbach M, Hasenberg T, Linke M, Kienle P, Post S, Ronellenfitsch U. Perioperative quality of care is modulated by process management with clinical pathways for fast-track surgery of the colon. International Journal of Colorectal Disease. 2011:1–9.
    1. Watcha MF, Issioui T, Klein KW, White PF. Costs and effectiveness of rofecoxib, celecoxib, and acetaminophen for preventing pain after ambulatory otolaryngologic surgery. Anesthesia and Analgesia. 2003;96(4):987–994.
    1. de Beer JDV, Winemaker MJ, Donnelly GAE, et al. Efficacy and safety of controlled-release oxycodone and standard therapies for postoperative pain after knee or hip replacement. Canadian Journal of Surgery. 2005;48(4):277–283.
    1. Recart A, Duchene D, White PF, Thomas T, Johnson DB, Cadeddu JA. Efficacy and safety of fast-track recovery strategy for patients undergoing laparoscopic nephrectomy. Journal of Endourology. 2005;19(10):1165–1169.
    1. MacMillan SLM, Kammerer-Doak D, Rogers RG, Parker KM. Early feeding and the incidence of gastrointestinal symptoms after major gynecologic surgery. Obstetrics and Gynecology. 2000;96(4):604–608.
    1. Schilder JM, Hurteau JA, Look KY, et al. A prospective controlled trial of early postoperative oral intake following major abdominal gynecologic surgery. Gynecologic Oncology. 1997;67(3):235–240.
    1. Basse L, Jakobsen DH, Billesbølle P, Werner M, Kehlet H. A clinical pathway to accelerate recovery after colonic resection. Annals of Surgery. 2000;232(1):51–57.
    1. Charoenkwan K, Phillipson G, Vutyavanich T. Early versus delayed (traditional) oral fluids and food for reducing complications after major abdominal gynaecologic surgery. Cochrane Database of Systematic Reviews. 2007;(4):p. CD004508.
    1. Minig L, Biffi R, Zanagnolo V, et al. Early oral versus “traditional” postoperative feeding in gynecologic oncology patients undergoing intestinal resection: a randomized controlled trial. Annals of Surgical Oncology. 2009;16(6):1660–1668.
    1. Noble EJ, Harris R, Hosie KB, Thomas S, Lewis SJ. Gum chewing reduces postoperative ileus? A systematic review and meta-analysis. International Journal of Surgery. 2009;7(2):100–105.
    1. Carlisle JB, Stevenson CA. Drugs for preventing postoperative nausea and vomiting. Cochrane Database of Systematic Reviews. 2006;3:p. CD004125.
    1. Wren SM, Martin M, Yoon JK, Bech F. Postoperative pneumonia-prevention program for the inpatient surgical ward. Journal of the American College of Surgeons. 2010;210(4):491–495.
    1. Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. British Journal of Anaesthesia. 1997;78(5):606–617.
    1. Marx C, Rasmussen T, Hjort Jakobsen D, et al. The effect of accelerated rehabilitation on recovery after surgery for ovarian malignancy. Acta Obstetricia et Gynecologica Scandinavica. 2006;85(4):488–492.
    1. Hansen CT, Sørensen M, Møller C, Ottesen B, Kehlet H. Effect of laxatives on gastrointestinal functional recovery in fast-track hysterectomy: a double-blind, placebo-controlled randomized study. American Journal of Obstetrics and Gynecology. 2007;196(4):311–e1.
    1. Kraus K, Fanning J. Prospective trial of early feeding and bowel stimulation after radical hysterectomy. American Journal of Obstetrics and Gynecology. 2000;182(5):996–998.
    1. Hendren S, Morris AM, Zhang W, Dimick J. Early discharge and hospital readmission after colectomy for cancer. Diseases of the Colon and Rectum. 2011;54(11):1362–1367.
    1. Sjetne IS, Krogstad U, Ødegård S, Engh ME. Improving quality by introducing enhanced recovery after surgery in a gynaecological department: consequences for ward nursing practice. Quality and Safety in Health Care. 2009;18(3):236–240.
    1. Vlug MS, Bartels SAL, Wind J. Which fast track elements predict early recovery after colon cancer surgery? Colorectal Disease. 2012;14(8):1001–1008.
    1. AIHW. Cancer in Australia, An Overview. Canberra, Ausrtalia: AIHW; 2008. (Cancer Series 46(Cat. No. CAN 42)).
    1. Kitchener H, Swart AM, Qian Q, Amos C, Parmar MK. Efficacy of systematic pelvic lymphadenectomy in endometrial cancer (MRC ASTEC trial): a randomised study. The Lancet. 2009;373(9658):125–136.
    1. Carter JR, Ding Z, Rose BR. HPV infection and cervical disease: a review. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2011;51(2):103–108.
    1. Carter J, Smirnova S. A personal experience with radical abdominal trachelectomy for the conservative management of invasive cervical cancer. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2011;51(2):177–182.
    1. Massad LS, Vogler G, Herzog TJ, Mutch DG. Correlates of length of stay in gynecologic oncology patients undergoing inpatient surgery. Gynecologic Oncology. 1993;51(2):214–218.
    1. Commonwealth of Australia. Australia: the healthiest country by 2020. Obesity in Australia: a need for urgent action. Technical Report. 2009;(1)
    1. World Health Organisation. Fact Sheet. 311. Geneva, Switzerland: WHO; 2006. Obesity and overweight.
    1. Anderson B, Connor JP, Andrews J, et al. Obesity and prognosis in endometrial cancer. American Journal of Obstetrics & Gynecology. 1996;174(4):1171–11788.
    1. Pellegrino A, Signorelli M, Fruscio R, et al. Feasibility and morbidity of total laparoscopic radical hysterectomy with or without pelvic limphadenectomy in obese women with stage i endometrial cancer. Archives of Gynecology and Obstetrics. 2009;279(5):655–660.
    1. Wright JD, Lewin SN, Barrena Medel NI, et al. Morbidity and mortality of surgery for endometrial cancer in the oldest old. American Journal of Obstetrics and Gynecology. 2011;205(1):66–e1.
    1. Khuri SF, Henderson WG, DePalma RG, et al. Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Annals of Surgery. 2005;242(3):326–343.
    1. Lachance JA, Everett EN, Greer B, et al. The effect of age on clinical/pathologic features, surgical morbidity, and outcome in patients with endometrial cancer. Gynecologic Oncology. 2006;101(3):470–475.

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