Opportunistic salpingectomy during non-gynaecological surgery in the United States: a population-based retrospective study

Dear Editor

Beginning in the early 2000s, histological and molecular studies revealed that high-grade serous carcinoma, the most common subtype of epithelial ovarian cancer, commonly originates in the fallopian tube epithelium rather than the ovarian surface epithelium¹. Indeed, retrospective data suggest that bilateral salpingectomy is associated with a reduced risk of ovarian cancer. A population-based cohort study comparing patients who had undergone salpingectomy versus unexposed controls in Sweden between 1973 and 2009 found an HR for ovarian cancer of 0.35 (95 per cent c.i. 0.17 to 0.73) among those with a history of bilateral salpingectomy, and a recent population-based cohort study in British Columbia found no cases of serous ovarian cancer among all individuals who underwent bilateral salpingectomy between 2008 and 2017^2,3. Furthermore, case–control studies comparing individuals with ovarian cancer with matched controls demonstrated an inverse association between history of bilateral salpingectomy and ovarian cancer with ORs of 0.22 (95 per cent c.i. 0.03 to 1.87) and 0.58 (95 per cent c.i. 0.36 to 0.95)^4,5.

Opportunistic salpingectomy is the removal of the fallopian tubes during surgery performed for other indications. Since 2011, at least nine International Federation of Gynecology and Obstetrics (FIGO) member societies have published statements supporting the consideration of opportunistic salpingectomy, including those representing Canada, the USA, and Great Britain^6–8. Correspondingly, the utilization of opportunistic salpingectomy during gynaecological procedures has increased rapidly; for example, in the USA, the rate of salpingectomy at the time of benign hysterectomy increased from 5.7 per cent in 2010 to 58.4 per cent in 2015^9–12.

Two studies by Tomasch et al.^13,14 have established the acceptability and feasibility of opportunistic salpingectomy during non-gynaecological surgery. In the first study, a majority of women aged greater than or equal to 45 years who were scheduled for elective laparoscopic cholecystectomy reported that they would accept concurrent opportunistic salpingectomy¹³. In a subsequent prospective feasibility study, salpingectomy was successfully performed in greater than 90 per cent of patients, with a median additional operating time of 13 min and no attributable complications¹⁴.

It is not known if opportunistic salpingectomy at the time of non-gynaecological surgery has been widely adopted. The aim of the present study was to estimate the incidence of opportunistic salpingectomy during non-gynaecological surgery at a population level in the USA.

A population-based, retrospective, cross-sectional observational study was done using discharge data from the National Inpatient Sample (NIS), Agency for Healthcare Research and Quality¹⁵. The NIS is an all-payer administrative claims database covering 98 per cent of the US population. From the NIS, all hospitalizations between 2016 and 2020 were identified, where procedure codes for bilateral salpingectomy were reported (Table S1). All procedure and diagnosis codes for selected hospitalizations were reviewed. Hospitalizations were excluded if bilateral salpingectomy was performed with an obstetric or gynaecological procedure (Table S2), if bilateral salpingectomy was the only procedure performed on a given hospital day, or if a gynaecological indication for surgery was inferred from discharge diagnosis codes (Table S3). Appropriate discharge weights were applied to obtain national estimates. Given the complex survey design of the NIS, 95 per cent uncertainty is given for the total number of patients, while other values are given as weighted point estimates.

From an initial sample of 1 558 020 hospital admissions involving bilateral salpingectomy operations from 2016 to 2020, a total of 735 (95 per cent c.i. 491 to 979) admissions were identified, where bilateral salpingectomy was performed during non-gynaecological surgery (Fig. S1).

Thus, 0.05 per cent of all inpatient bilateral salpingectomies were performed during non-gynaecological surgery. Bilateral salpingectomy was performed concurrently with bowel resection or ostomy surgery (27.2 per cent, 200/735), breast surgery (8.2 per cent, 60/735), cholecystectomy (7.5 per cent, 55/735), gastric bypass or sleeve gastrectomy (29.2 per cent, 215/735), and hernia repair (19.7 per cent, 145/735) (Fig. 1). Most hospitalizations were elective (85.7 per cent, 630/735). Procedures were more commonly done via laparoscopy (54.4 per cent, 400/735) than by robotic-assisted laparoscopy (14.3 per cent, 105/735) or open surgery (31.3 per cent, 230/735). The median patient age was 37 (interquartile range 34–43) years, the median length of stay was 2 (interquartile range 1–4) days, and the median total hospitalization charges were $55 657 (interquartile range $32 310–$95 392).

Fig. 1.

Non-gynaecological inpatient surgeries where opportunistic salpingectomy was performed, 2016–2020

An error bar represents the 95 per cent c.i. around the total annual number of hospitalizations.

These results indicate that opportunistic salpingectomy during non-gynaecological inpatient surgery was rare in the USA from 2016 to 2020. Opportunistic salpingectomy during non-gynaecological surgery was most often performed with elective laparoscopic abdominal procedures. For this study, salpingectomy during breast surgery was considered opportunistic as anaesthesia-related risks had been incurred, but the degree to which salpingectomy during non-abdominal surgery is truly opportunistic is debatable. Interestingly, all cases of salpingectomy during appendectomy involved a discharge diagnosis code of salpingitis, and thus these procedures were considered gynecologically indicated and not opportunistic.

Opportunistic salpingectomy during non-gynaecological surgery is an underutilized strategy for cancer prevention. Each year an estimated 1 850 000 female patients in the USA undergo the non-gynaecological surgeries identified in the present study¹⁶. If opportunistic salpingectomy was attempted in 60 per cent of these surgeries with a success rate of 90 per cent, assuming a reduction in ovarian cancer risk between 40–65 per cent, this strategy would prevent between 3600 and 5800 deaths from ovarian cancer per year of surgery nationally^2,5,14,17.

Future research on safety, feasibility, and implementation is needed to promote expanded adoption of opportunistic salpingectomy during non-gynaecological surgery. While most data suggest that salpingectomy during gynaecological surgery is safe and without significant effect on ovarian function, safety data pertaining to non-gynaecological surgery are limited to a single prospective study to the best of the authors’ knowledge^14,18,19. Recommendation of opportunistic salpingectomy is broad, but not universal; given a lack of prospective evidence, FIGO member statements representing Germany, Sweden, Norway, and France are presently ambivalent on opportunistic salpingectomy⁸. Finally, to promote wider adoption of opportunistic salpingectomy during non-gynaecological surgery, it will be necessary to establish logistic best practices around what surgical team or teams should counsel, consent, and perform the salpingectomy.

Limitations of this study derive from its use of administrative claims data, which may be subject to error or misclassification. The NIS only samples inpatient surgeries, and thus ambulatory procedures are not captured. Study years before 2016 were not included due to a transition from the ICD-9 to ICD-10 coding system in 2015 that confounds direct comparison of results.

Funding

This work was supported by the National Institute of Mental Health (T32MH112485, J.L.).

Author contributions

Ann M. Cathcart (Conceptualization, Data curation, Formal analysis, Methodology, Writing—original draft, Writing—review & editing), Ross Harrison (Methodology, Supervision, Writing—review & editing), and James Luccarelli (Data curation, Funding acquisition, Methodology, Resources, Supervision, Writing—review & editing).

Disclosure

A.M.C. is a member of the Product Advisory Board for Delfina Care Inc., San Jose, CA, USA. J.L. holds equity in Revial Therapuetics, Inc., and grants from the National Institute of Mental Health and Harvard Medical School. The authors declare no other conflict of interest.

Supplementary material

Supplementary material is available at BJS online.

Data availability

The data used in this study are available at: www.hcup-us.ahrq.gov/nisoverview.jsp (Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS), 2022).