Risk Factors for Bowel Injury in Hysterectomy for Benign Indications

Cici R Zhu, Zhu CR, Mallick R, Ranjeeta Mallick, Sukhbir S. Singh, Singh SS, Auer R, Rebecca Auer, Solnik J, Jonathon Solnik, Choudhry AJ, Abdul Jamil Choudhry, Innie Chen
Obstetrics and gynecology · 2020 · vol. 136(4) , pp. 803–810 · doi:10.1097/AOG.0000000000004007 · PMID:32925612
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Among women undergoing hysterectomy for benign indications, older age and abdominal surgical approach significantly increased bowel injury risk, with endometriosis also associated with higher odds compared to other surgical indications.

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This retrospective cohort study analyzed data from over 155,000 women undergoing hysterectomy for benign indications to identify risk factors for intraoperative bowel injury. The researchers found that an operative indication of endometriosis was significantly associated with a higher likelihood of bowel injury compared to other conditions such as uterine leiomyomas or menstrual disorders. Additionally, the abdominal surgical approach carried a substantially greater risk of bowel injury than vaginal or laparoscopic methods, even after adjusting for patient age and other clinical confounders. Relevance to endometriosis: listed as one indication for GnRH antagonists, though the paper's main focus is uterine fibroids.

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Abstract

OBJECTIVE: To estimate the incidence and risk factors for bowel injury in women undergoing hysterectomy for benign indications. METHODS: A retrospective cohort study was conducted among women undergoing hysterectomy for benign indications from 2012 to 2016 at institutes participating in the American College of Surgeons National Surgical Quality Improvement Program, including both inpatient and outpatient settings. Bowel injury was identified using Current Procedural Terminology codes as patients who underwent bowel repair at the time of hysterectomy or postoperatively within 30 days. Multivariate logistic regression models were used to control for patient clinical factors and perioperative factors. RESULTS: Bowel injury occurred in 610 of 155,557 (0.39%) included women. After bivariate analysis, factors associated with bowel injury included age, race, body mass index, American Society of Anesthesiologists classification, increased operative time, surgical approach, type of hysterectomy, lysis of adhesions, and operative indication. After adjusting for potential confounders, bowel injury was found associated with older age, surgical indication of endometriosis, and abdominal surgical approach. Compared with the surgical indication of endometriosis (n=63/10,625), the surgical indications of menstrual disorder (odds ratio [OR] 0.33, 95% CI 0.23-0.47; adjusted odds ratio [aOR] 0.33, 95% CI 0.23-0.48; n=67/34,168), uterine leiomyomas (OR 0.80, 95% CI 0.61-1.05; aOR 0.44, 95% CI 0.33-0.59; n=243/51,232), and genital prolapse (OR 0.30, 95% CI 0.20-0.45; aOR 0.41, 95% CI 0.25-0.67; n=36/20,384) were each associated with lower odds of bowel injury. Compared with the vaginal approach to hysterectomy (n=27/27,434), the abdominal approach was found to have significantly increased odds of bowel injury (OR 10.80, 95% CI 7.31-15.95; aOR 10.49 95% CI 6.42-17.12; n=401/38,106); the laparoscopic approach had smaller but significantly increased odds (OR 2.06, 95% CI 1.37-3.08; aOR 2.03 95% CI 1.24-3.34; n=182/90,017) as well. CONCLUSION: Increased risk of bowel injury is associated with endometriosis and the abdominal surgical approach to hysterectomy. These findings have implications for the surgical care of women with benign uterine disease.
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Objective

To estimate the incidence and risk factors for bowel injury in women undergoing hysterectomy for benign indications.

Methods

A retrospective cohort study was conducted among women undergoing hysterectomy for benign indications from 2012 to 2016 at institutes participating in the American College of Surgeons National Surgical Quality Improvement Program, including both inpatient and outpatient settings. Bowel injury was identified using Current Procedural Terminology codes as patients who underwent bowel repair at the time of hysterectomy or postoperatively within 30 days. Multivariate logistic regression models were used to control for patient clinical factors and perioperative factors.

Results

Bowel injury occurred in 610 of 155,557 (0.39%) included women. After bivariate analysis, factors associated with bowel injury included age, race, body mass index, American Society of Anesthesiologists classification, increased operative time, surgical approach, type of hysterectomy, lysis of adhesions, and operative indication. After adjusting for potential confounders, bowel injury was found associated with older age, surgical indication of endometriosis, and abdominal surgical approach. Compared with the surgical indication of endometriosis (n=63/10,625), the surgical indications of menstrual disorder (odds ratio [OR] 0.33, 95% CI 0.23–0.47; adjusted odds ratio [aOR] 0.33, 95% CI 0.23–0.48; n=67/34,168), uterine leiomyomas (OR 0.80, 95% CI 0.61–1.05; aOR 0.44, 95% CI 0.33–0.59; n=243/51,232), and genital prolapse (OR 0.30, 95% CI 0.20–0.45; aOR 0.41, 95% CI 0.25–0.67; n=36/20,384) were each associated with lower odds of bowel injury. Compared with the vaginal approach to hysterectomy (n=27/27,434), the abdominal approach was found to have significantly increased odds of bowel injury (OR 10.80, 95% CI 7.31–15.95; aOR 10.49 95% CI 6.42–17.12; n=401/38,106); the laparoscopic approach had smaller but significantly increased odds (OR 2.06, 95% CI 1.37–3.08; aOR 2.03 95% CI 1.24–3.34; n=182/90,017) as well.

Conclusion

Increased risk of bowel injury is associated with endometriosis and the abdominal surgical approach to hysterectomy. These findings have implications for the surgical care of women with benign uterine disease. For women undergoing hysterectomy for benign indications, bowel injury is associated with patient age, an operative indication of endometriosis, and the abdominal approach to surgery.

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Condition tags

endometriosis

MeSH descriptors

Endometriosis Gastrointestinal Tract Genital Diseases, Female Hysterectomy Hysterectomy Hysterectomy Hysterectomy Hysterectomy, Vaginal Intraoperative Complications Intraoperative Complications Intraoperative Complications Intraoperative Complications Laparoscopy Laparotomy Canada Canada Canada Endometriosis Endometriosis Female

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