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SHORT-TERM RECOVERY AFTER SUBTOTAL AND TOTAL ABDOMINAL HYSTERECTOMY—A RANDOMISED

CLINICAL TRIALCompiled by:Christine Verina 2013-061-003Vitya Chandika 2013-061-062Priscila Stevanni 2013-061-066

INTRODUCTION

For benign gynecological disorders subtotal abdominal

hysterectomy (SH) has gained popularity compared with

total abdominal hysterectomy (TH) because of a shorter

operating time, less peroperative bleeding and fewer peri-

operative complications.

Aims:

to determine whether the day-by-day postoperative

recovery differed between SH and TH, and to analyze

factors associated with postoperative recovery and sick

leave.

Hypothesis:

SH, because of its presumed less invasive character and

lower complication rate, would give a faster day-by- day

recovery in general wellbeing than TH.

METHODS

The day-by-day recovery of general wellbeing was

measured on a visual analogue scale in a diary 7

days preoperatively and 35 days postoperatively.

SURGERY

The surgical technique of the hysterectomy was left to the

surgeon’s discretion.

The patient was discharged from the hospital when she

was mobilized and had sufficient pain relief with oral

analgesics.

The patient was contacted regarding general wellbeing

approximately 10 days after discharge and then once

weekly until the patient considered she had recovered.

Patient visited the outpatient clinic after 5 weeks. Data on

postoperative complications and the period of sick leave

were recorded.

Measurement of general well-being• One week before surgery and continuing daily until day 35

postoperatively• Diary concerning their general well-being• Visual analogue scale (VAS) ranging from 0-100• They were asked to report their consumption of

analgesics

Psychological measures• Psychological functioning was measured 1 week

preoperatively by psychometric tests• Psychological General Well-Being (PGWB)

Consists of 22 questions referring to anxiety, depression, wellbeing, self-control, health, and vitality. Rated on a scale 1-6

• Women’s Health Questionnaire (WHQ)Consists of 36 questions referring minor psychological and somatic symptoms experienced by peri- and postmenopausal women. Rated on a scale 1-6

• State Trait Anxiety Inventory (STAI)Consists of 20 statements that evaluate how the respondents feels ‘generally’

• Beck’s Depression Inventory (BDI)Consist of 21 questions. It’s a quantative self-reporting scale for measuring depression and its severity

Statistics• Intention-to-treat principle• Continuous data : t test• Nominal data : Yates corrected Chi square & Fisher’s

exact test• ANOVA repeated measurements was used to compare

the results of general wellbeing and psychological measurements between two groups

• Statistical significance was accepted at the 5% level

RESULTS

RESULTS• The demographic and clinical data did not differ

significantly between two groups• Preoperative data, the operating time was significantly

longer, and prophylactic antibiotics more frequently used in TH than in SH

• No significant differences between two groups in use of parenterally or enterally administered analgesics

Association between day-by-day recovery of general wellbeing and mode of hysterectomy• Day-by-day general wellbeing did not differ significantly

between the hysterectomy groups in the pre and postoperative periods (p=0.9010, p=0.5048)

• There were highly significant main effects over time (p<0.0001) for the pre and postoperative periods

• Postoperative period, a significant interaction effect was observed (p=0.0029)

• The speed of recovery was initially higher for women in SH than TH group, but later on vice versa

Complications after surgery• No complications : 68 (72%) in SH and 64 (76%)

in TH• Major complications : 7 (7,4%) SH and 4 (4,8%) in TH• Minor complications : 19 (20,2%) in SH and 17 (20,2%) in

TH

Factors associated with postoperative recovery day-by-day general wellbeing• Post operative day-by-day wellbeing was strongly

negatively associated with the occurrence of complications (p= 0.0004 main effect between groups, p= 0.0001 main effect over time and no significant reaction)

• There were strong associations with preoperative general wellbeing for all 4 psychometric tests

SICK LEAVE

• The duration of sick leave was also strongly associated

with recovery in terms of day-by-day general wellbeing

postoperatively

• The sick leave was strongly associated with the

occurrence of complications (40 ± 13 days with

complications versus 31 ± 8 days without complications; P

< 0.001).

DISCUSSION

• This study showed no difference in the day-by-day recovery

of self-reported general wellbeing between women

undergoing subtotal or total abdominal hysterectomy

• The use of a VAS to measure general wellbeing may seem

to be a crude method

• In order to detect changes in psychological wellbeing we

used four validated tests: two generic (PQWB and WHQ)

and two specific (STAI and BDI)

• If the sick leave > 35 days the patient was appointed to

visit the doctor in order to be examined and evaluated for

further prolongation of the sick leave, and to receive

treatment if necessary.

• The operation time was statistically significantly longer in

the TH group

• The use of postoperative analgesics was similar in the two

groups

• Psychological wellbeing is of importance for the length of

the recovery period

• In conclusion, the day-by-day recovery of general wellbeing

after SH and TH is equal.

• The occurrence of postoperative complications and a low

preoperative level of psychological wellbeing impair the

postoperative recovery significantly, and prolong the

duration of sick leave.

• Further studies should be encouraged to determine the

impact of intervention strategies on the recovery of women

with low psychological capacity after hysterectomy, efforts

should be made to reduce postoperative complications,