Peripheral Infusion Ports for Central Venous Access in Patients with Gynecologic Malignancies

During treatment for gynecologic malignancies, many patients require frequent or prolonged intravenous access. Implantable permanent venous access devices are useful in assuring adequate access and improving quality of life. A new technique for central venous access by peripheral placement of a subcutaneous infusion port was evaluated in 18 women undergoing treatment for gynecologic malignancies. Patients were followed prospectively with a mean follow-up of 105 days. Six catheters required removal because of complications, including 1 patient with a catheter site infection and 5 patients (26%) with catheter-related thrombosis. Although the rate of immediate insertion-related complications was low, the incidence of deep venous thrombosis was markedly increased over that reported with other central venous access devices.     

Externalized Groshong Catheters and Hickman Ports for Central Venous Access in Gynecologic Oncology Patients

There is a demand on gynecologic oncology services for semi-permanent cannulization of central veins to improve the quality of life in cancer patients by circumventing the need for frequent peripheral venous punctures. Central venous thrombosis and sepsis are the major complications with these lines. We reviewed our experience with the externalized Groshong catheters and subcutaneously implanted Hickman ports in 104 gynecologic oncology patients requiring either chemotherapy (56), hyperalimentation (5), or supportive care (43). All devices were inserted under the supervision of one primary gynecologic oncologist. Groshong catheters and Hickman ports remained in place for a median of 68.5 and 210 days, respectively (P < 0.001). Thrombosis occurred in association with 4.8% of catheters and was exclusive to the Groshong catheters. Line sepsis occurred in 32% of Groshong catheters and 16.2% of Hickman ports (P = 0.04). Infection rates were not higher in dual-lumen compared to single-lumen Groshong catheters. Staphylococcus epidermidis was the commonest isolate in line infections. The majority of lines were salvaged despite infectious complications. Malfunction of the catheter was equally common in both groups (10.5-13.5%), but was complete, necessitating replacement of only 2.9% of lines. The Groshong catheters took less time to insert (P < 0.003). The externalized Groshong catheter remains a useful alternative to the subcutaneously implanted ports, especially when relatively short-term use is anticipated, but gynecologic oncologists should be aware that there is an increased frequency of complications with the externalized catheter.     

Prothrombin Fragment F 1 + 2 Plasma Concentrations in Patients with Gynecologic Malignancies

Malignant diseases have been shown to cause hypercoagulable states. Elevated prothrombin fragment F 1 + 2 plasma levels occur, when prothrombin is converted into thrombin by factor Xa. In order to evaluate the role of prothrombin fragment F 1 + 2 as an indicator for hemostatic disorders in patients with gynecologic malignancies, plasma levels of 76 patients with various malignancies of the female genital tract and those of 25 healthy subjects were investigated. Fifty-two of 76 (68.4%) patients with malignant diseases showed elevated F 1 + 2 plasma concentrations, whereas no elevated plasma levels were observed in the control group. Mean values of F 1 + 2 in the study group and the controls were 1.94 ± 1.63 and 0.89 ± 0.07 nmol/liter, respectively (P < 0.01). These results provide further evidence that gynecologic malignancies can induce hypercoagulable states.     

Factors Predicting Subcutaneous Implanted Central Venous Port Function: The Relationship between Catheter Tip Location and Port Failure in Patients with Gynecologic Malignancies

OBJECTIVE: We set out to determine the factors that predict subcutaneous implanted central venous port function. Specifically, we sought to determine whether the location of the catheter tip is correlated with port failure. METHODS: A review of all gynecologic oncology patients who underwent initial port placement between 1993 and 1998 was undertaken. The initial chest radiograph following port placement was reviewed, and the venous location of the catheter tip was recorded. Patients were followed until port removal, death, or the last documentation of port function. RESULTS: Two hundred thirty-six patients underwent port placement during the study period. The majority of patients (97%) had their port placed for intravenous chemotherapy. The median time of port duration in patients with a functional port was 21.6 months. Forty of the 236 ports (17%) were removed because of device malfunction. Catheter tips were located in the central venous system in 164 (69%) cases and outside of the central venous system in 72 (31%) cases. Removal secondary to malfunction was significantly higher when the catheter tip was located outside of the central venous system (30/72 (42%) versus 10/164 (6%), P = 0.001). By life-table analysis, ports removed for malfunction with their tips located centrally had a significantly longer median duration of functional use than those whose tips were located peripherally (78 versus 44 months, P = 0.0001). CONCLUSIONS: The rate of port removal secondary to malfunction is significantly less if the catheter tip is located in the central venous system. Confirmation of the location of the catheter tip is imperative for the long-term function of a subcutaneous implanted central venous port.     

妇科腹腔镜手术878例经验总结

目的：总结妇科腹腔镜手术各种操作技术及其应用价值和注意事项。方法：回顾分析８７８例腹腔镜手术的经验，根据操作难度分为Ⅰ级、Ⅱ级、Ⅲ级，比较其手术时间、术后病率及并发症。Ⅰ级操作为内凝法，１２４例（Ｉ级组）；Ⅱ级操作为套扎、水分离法，６５３例（Ⅱ级组）；Ⅲ级操作为电切电凝、结扎缝合，１０１例（Ⅲ级组）。结果：８６６例手术全过程在镜下完成，无术时并发症；１２例因手术困难中转开腹手术。平均手术时间，Ⅰ级组４９分、Ⅱ级组７７分、Ⅲ级组１７１分。术后病率Ⅰ级组０．０％、Ⅱ级组４．８％、Ⅲ级组３３．３％。Ⅲ级组中有１例子宫切除术后发生感染、大出血。Ⅰ、Ⅱ级组无术后并发症、临床效果良好。结论：根据操作难度循序渐进地熟练操作技术，以进行相应手术，可获满意治疗效果并可望安全有效地开展妇科腹腔镜手术。     

Erythropoietin Treatment under Polychemotherapy in Patients with Gynecologic Malignancies: A Prospective, Randomized, Double-Blind Placebo-Controlled Multicenter Study

In order to examine the influence of erythropoietin (rHuEPO) on serum hemoglobin levels, transfusion requirements, and quality of life in patients with gynecologic malignancies under polychemotherapy and chronic tumor anemia (hemoglobin <11 g/dl), we performed a prospective, randomized, double-blinded placebo-controlled clinical trial. Between October 1992 and October 1993, 35 patients from 5 gynecologic departments were entered into this trial. Inclusion criteria were hemoglobin level <11 g/dl, ferritin level >29 ng/ml, stool negative for occult blood, and life expectancy for more than 3 months. Patients received either 150 U/kg body wt rHuEPO (Erypo by Cilag-Janssen) sc three times a week for 12 weeks (n= 23) or a placebo (n= 12). If the hemoglobin levels of the 4th, 8th, or 12th week were >2 g/dl above the baseline value and/or >12 g/dl, the patient was classified as a responder. Patients who required blood transfusions (hemoglobin <8 g/dl, erythrocytes <3 × 10⁶/ml, or clinical symptoms of anemia) were classified as nonresponders. A nonvalidated quality of life questionnaire was completed by the patient at the beginning of the treatment and then every fourth week before receiving chemotherapy. In the rHuEPO group 56.6% of the patients responded to the treatment (χ²= 10.79,P= 0.001) and only 5 patients (21.7%) required blood transfusions, whereas 8 of 12 patients in the placebo group (66.6%) had to be transfused (χ²= 6.81,P= 0.009). Quality of life did not differ significantly between the rHuEPO group and the placebo group of patients. Within the rHuEPO group those patients that responded showed a significant increase in physical activity after response in comparison to the preresponsive phase (P= 0.02, pairedttest). We therefore concluded that rHuEPO significantly increases serum hemoglobin levels and decreases transfusions requirements while maintaining quality of life in patients with gynecological malignancies who are undergoing polychemotherapy.     

A Randomized Study Comparing Retroperitoneal Drainage with No Drainage after Lymphadenectomy in Gynecologic Malignancies

Objective:To evaluate the clinical effectiveness of retroperitoneal drainage following lymphadenectomy in gynecologic surgery.Methods:One hundred thirty-seven consecutive patients undergoing systematic lymphadenectomy for gynecologic malignancies were randomized to receive (Group A, 68) or not (Group B, 69) retroperitoneal drainage. The pelvic peritoneum and the paracolic gutters were not sutured after node dissection. Perioperative data and complications were recorded.Results:Clinical and surgical parameters were comparable in the two groups. Postoperative hospital stay was significantly shorter in Group B (P< 0.001), whereas the complication rate was significantly higher in Group A (P= 0.01). This was mainly due to a significant increase in lymphocyst and lymphocyst-related morbidity. Sonographic monitoring for lymphocyst showed free abdominal fluid in 18% of drained and 36% of not-drained patients (P= 0.03). Symptomatic ascites developed in 2 drained (3%) and 3 not-drained (4%) patients (NS), respectively.Conclusions:Prophylactic drainage of the retroperitoneum seems to increase lymphadenectomy-related morbidity and postoperative stay. Therefore, routine drainage following lymphadenectomy seems to be no longer indicated when the retroperitoneum is left open.     

机器人手术在妇科恶性肿瘤手术治疗中的应用

机器人技术的出现使外科微创手术进入新的发展阶段.在妇科恶性肿瘤手术治疗中机器人也逐步得到应用,其主要应用于宫颈癌的广泛性全子宫切除和盆腔淋巴清扫术,此外机器人根治性宫颈切除术、晚期宫颈癌分期手术及复发性宫颈癌的盆腔脏器切除术也有相关报道;子宫内膜癌和卵巢癌的机器人分期手术也日趋增多.目前,机器人手术多是回顾性病例报告,...     

机器人手术在妇科恶性肿瘤手术治疗中的应用

机器人技术的出现使外科微创手术进入新的发展阶段。在妇科恶性肿瘤手术治疗中机器人也逐步得到应用,其主要应用于宫颈癌的广泛性全子宫切除和盆腔淋巴清扫术,此外机器人根治性宫颈切除术、晚期宫颈癌分期手术及复发性宫颈癌的盆腔脏器切除术也有相关报道;子宫内膜癌和卵巢癌的机器人分期手术也日趋增多。目前,机器人手术多是回顾性病例报告,缺乏随机对照、大样本比较性研究,其适应证和手术效果还需要大量临床探索,以作出全面的评价。     

Venous Thromboembolism in Minimally Invasive Gynecologic Surgery: A Systematic Review

Venous thromboembolism (VTE) is the leading cause of preventable healthcare-related death after surgery. Although there is a large body of research on VTE in the general population as well as risk-assessment tools, evidence specific to the current practices in gynecologic surgery is more sparse. This review article seeks to discuss current literature on VTE in gynecologic surgery, with a focus on minimally invasive surgery. Evidence on risk factors for VTE in gynecologic surgery is evaluated as well as current recommendations use of thromboprophylaxis for prevention of VTE. Despite data showing that minimally invasive gynecologic surgery independently decreases risk of VTE compared with laparotomy, current clinical risk assessment tools and guidelines do not incorporate mode of surgery into recommendations for perioperative VTE prevention.     

妇科恶性肿瘤腹腔镜术后穿刺孔转移的研究进展

腹腔镜术后腹部穿刺孔肿瘤种植或转移（port site metastasis,PSM）是腹腔镜手术后特有并发症;发病率与疾病的恶性程度、肿瘤种类、组织学类型、国际妇产科联盟（FIGO）分期、有无腹水、腹腔镜的目的等因素有关,妇科恶性肿瘤中卵巢癌的PSM发生率最高,晚期卵巢癌、大量腹水、恶性肿瘤破裂等与PSM发生密切相关;PSM发病与肿瘤生物学特性、外科手术技术、CO2及气腹、能量器械使用、宿主免疫反应等有关;选择合适病例、术中穿刺尽量减少组织损伤、严格遵守外科无瘤原则、术中避免CO2气体的泄露及骤然的释放、缩短气腹时间、术毕充分冲洗腹腔、器械及穿刺口,缝合5 mm以上的穿刺孔等是预防PSM发生的关键方法。     

妇科肿瘤合并急性下肢深静脉血栓形成14例临床分析

目的:研究妇科肿瘤合并急性下肢深静脉血栓(DVT)形成的危险因素、临床特点和诊治方法。方法:回顾性分析我院1 4例妇科肿瘤合并急性下肢DVT患者的临床资料。结果:1 4例中4例恶性肿瘤,3例发展为肺栓塞。1 3例经彩超检查确诊。9例手术取栓,其中4例妇科手术同时外科取栓治疗;5例保守治疗。1 3例治疗后好转出院,1例死亡。结论:妇科肿瘤合并DVT应引起充分重视,彩超检查有助于DVT的诊断。急性DVT保守或手术治疗均有效。如DVT与妇科肿瘤有关,可在妇科手术同时行取栓术,联合抗凝、溶栓、祛聚、扩血管等综合治疗,防止血栓再发和促进后期再通。对有高危因素者手术前后应预防性应用抗凝剂。     

Minimally Invasive Pelvic Exenteration for Gynecologic Malignancies: A Multi-Institutional Case Series and Review of the Literature

Study ObjectiveTo assess the feasibility and efficacy of minimally invasive pelvic exenteration (MIPE) in a multi-institutional Italian case series of women with gynecologic cancer and a review of the literature.DesignRetrospective cohort study (Canadian Task Force classification II-2).SettingThree Italian university/teaching hospitals: “Agostino Gemelli” Foundation University Hospital in Rome, "ARNAS Civico Di Cristina Benfratelli” Hospital in Palermo, and “Maggiore della Carità” Hospital in Novara.PatientsWe reviewed all consecutive cases with gynecologic malignancies in this multi-institutional setting recorded between March 2014 and June 2017. Women with primary or central recurrent/persistent gynecologic cancer considered suitable for exenterative surgery after multidisciplinary tumor board discussion were included. Clinicopathological, perioperative, and survival data were retrieved from the institutional electronic database (STAR center).InterventionsAll patients underwent total or anterior MIPE with a laparoscopic or robotic approach.Measurements and Main ResultsTwenty-three patients underwent MIPE during the study period, including 12 (52.1%) by a laparoscopic approach and 11 (47.9%) by a robotic approach. All but 1 woman underwent MIPE for recurrent disease. The overall median operative time was 540 minutes (range, 310–720 minutes) with laparoscopy, slightly longer than with the robotic approach (p = .04). Median estimated blood loss was 400 mL (range, 200–600 mL). R0 resection was achieved in 17 of 23 patients (73.9%). There were no perioperative deaths. Early major postoperative complications occurred in 2 patients (8.7%). The median duration of hospitalization was 10 days (range, 6–33 days). With a median follow-up of 15 months, 11 patients (47.8%) developed recurrence. The median disease-free survival was 11 months (range, 5–18 months). To date, 155 MIPEs for gynecologic cancers have been reported in the literature. Among these, 12.6% had major postoperative complications, and overall postoperative mortality was 0.6%.ConclusionMIPE is a feasible procedure with low rate of intraoperative and postoperative complications. Careful patient selection is crucial to balance perioperative risks and potential survival benefits and to achieve complete tumor resection.     

The Groshong Catheter as an Intraperitoneal Access Device in the Treatment of Ovarian Cancer Patients

With the development of new intraperitoneal treatments in ovarian cancer, safe and convenient access to the peritoneal cavity is now required. This report reviews the University of Alabama at Birmingham's experience with the Groshong catheter as an intraperitoneal access device. The Groshong was easily inserted intraperitoneally in 20 ovarian cancer patients and used to deliver 81 courses of intraperitoneal therapy over 2310 patient-days. There were no catheter-related complications during treatment and only one exit site infection after catheter removal. Further investigation of the Groshong catheter as a novel intraperitoneal access device appears warranted.     

老年妇科病人的围手术期处理

目的总结老年妇科病人的围手术期处理经验,提高老年妇女手术治疗水平.方法对1997年1月至1999年12月本院收治的老年妇科手术病人304例围手术期资料进行分析.结果资料显示老年妇科手术患者中82.2%的病人合并有心血管方面的疾病和糖尿病等疾患.老年妇女的手术疾病中以恶性肿瘤占第一位(41.8%)、子宫脱垂占第二位(30.3%)、其次为良性肿瘤(27.9%).术后有发生心衰、肺部感染、切口愈合不良等并发症.其中有1例术后并发心律失常死亡.结论只要术前充分准备,对合并症积极控制,选择适当的术式和麻醉,术中术后严密监护,老年妇科患者是可以安全度过围手术期的.     

S100A14在妇科肿瘤发生发展中的研究进展

目前生殖系统肿瘤占女性全身肿瘤的15%,临床上迫切需要寻找一种能指导治疗及评估预后的生物标志物。S100A14是钙结合蛋白家族成员之一,在多种肿瘤组织中表达异常,与肿瘤的发生、发展和侵袭、转移关系密切。近年来,越来越多的研究表明S100A14表达与妇科肿瘤的临床病理分期、分化程度及淋巴结转移具有相关性,有望成为一个特异性肿瘤标志物。目前S100A14在妇科肿瘤发生、发展进程中的作用机制尚不明确,较为接受的说法是S100A14通过激活相关细胞信号转导通路,导致相关细胞因子表达水平变化,从而影响细胞周期的正常调控。深入研究S100A14在妇科肿瘤中的作用机制,靶向干预其作用过程,可为临床治疗妇科肿瘤提供新思路。现就S100A14在妇科肿瘤中的表达情况及其作用机制进行综述。     

A Case Series of Patients with Large Uterine Fibroids and Venous Thromboembolisms

ObjectiveThe purpose of this case series is to identify the clinical characteristics of women with uterine fibroids who developed venous thromboembolisms (VTE) and possible risk factors for the development of VTE in this group.Data SourcesWe conducted a systematic search of the Medline, Embase, Cochrane and Scopus databases to retrieve case reports and case series that describe women with an enlarged uterus and VTE. The databases were searched up to August 2019.Study SelectionA total of 1485 articles were identified by a librarian. All case series and case reports that reported uterine weight and size of the fibroids were included.Data Extraction and SynthesisA total of 27 articles were included, describing 35 patients who developed VTE in the presence of uterine fibroids. On average, the uterus measured 22.9 ± 5.0 weeks gestational age and occupied a volume of 2715 cm³ (interquartile range 1296.3–3878.8) on imaging. Two-thirds (60%) of VTEs occurred on the left side, and 87% showed signs of venous compression on imaging. Most patients (89%) required surgical management to relieve the compression caused by the enlarged uterus.ConclusionVTE in cases of large uterine leiomyomas can be associated with mechanical compression, which requires surgical management to relieve compression. There is an obvious increased risk of VTE in patients with venous stasis secondary to uterine compression; however, there is no current evidence evaluating the use of anticoagulation in such patients. Further research is required to determine the role of prophylactic anticoagulation in reducing the risk of VTE in high-risk patients with large uterine fibroids.     

Laparoscopic Access with Optical Gasless Trocar: A Single-center Experience of 7431 Procedures

Study ObjectiveTo analyze the complications experienced and describe laparoscopic surgery using a gasless optical trocar.DesignA retrospective study.SettingA department of obstetrics and gynecology in a tertiary center in Italy.PatientsSeven thousand four hundred thirty-one surgical procedures were performed.InterventionsFrom the hospital database, data were evaluated regarding major complications of laparoscopy with the ENDOPATH XCEL Bladeless Trocar (Ethicon, Johnson & Johnson, Somerville, NJ) performed between 2000 and 2017 by different laparoscopic surgeons.Measurements and Main ResultsThe mean age of the patients was 40.66 ± 12.06 years (range, 13–91 years). The mean body mass index was 22.12 ± 3.64 kg/m² (range, 15.74–41.51 kg/m²). The overall complication rate was 0.31% (23/7431 cases). Major complications included stomach perforation in 1 procedure (0.014%), ileal perforation in 2 procedures (0.028%), and blood vessel perforation in 1 procedure (0.014%). Twelve procedures were completed with initial access through the omentum and 2 through an ovarian cyst. In 5 procedures (0.067%), conversion to laparotomy was required because the optical trocar failed to reach the abdominal cavity. With regard to complications requiring further intervention (n = 9), the rate of complications was 0.12%.ConclusionsThe optical gasless trocar is a feasible laparoscopic entry technique. The complication rate is lower than those reported previously.