The effect of anesthesia choice on post-operative outcomes in women undergoing exploratory laparotomy for a suspected gynecologic malignancy

Objective

To determine how anesthesia choice in women undergoing laparotomy for gynecologic malignancy affects pain control and narcotic use.

Methods

This is a retrospective study of women who underwent laparotomy for suspected gynecologic malignancy from May 2012 to January 2013. Patients were categorized into one of three groups: 1) patient controlled analgesia (PCA); 2) PCA + transversus abdominis plane block (TAP); and 3) patient-controlled epidural analgesia (PCEA). Mean narcotic use and patient reported pain scores were compared.

Results

The analysis includes 112 women (44 PCA, 30 TAP, 38 PCEA). Intraoperative factors were not different between groups with the exception of a significant difference in the rate of intra-operative complications (p = 0.020), with lower rates in the PCEA group. The groups differed in intravenous narcotic use in each of the first three postoperative days (day 0: p = 0.014; day 1: p < 0.0001; day 2: p = 0.048), with patients in the TAP group using the least on day 0 and those in the PCEA group using less on postoperative days 1 and 2. In addition, the PCEA group reported lower pain scores on postoperative days 1 and 2 (day 1: p = 0.046; day 2: p = 0.008).

Conclusions

The use of patient controlled epidural anesthesia after laparotomy for gynecologic malignancy is associated with decreased IV and PO narcotic use and improved pain control without increasing complications or length of hospital stay. Further investigation with prospective randomized trials is warranted to elucidate the optimal post-operative pain management technique.     

Infiltración de los ligamentos uterosacros con un anestésico local de larga duración en pacientes sometidas a histerectomía vaginal

Objective

To determine whether infiltration of the uterosacral ligaments with a long-acting anesthetic during vaginal hysterectomy reduces the use of other forms of postoperative analgesia with possible morbidity.

Subjects and methods

We performed a controlled, randomized, double-blind clinical trial with two groups of patients. In the study group (45 patients), 5 mL ropivacaine at 0.75% was injected in each uterosacral ligament during the intervention. Patients in the control group did not receive any paracervical injections. Postoperative pain was evaluated at 2:30, 3:30, 13:30, and 25:30 hours after initiation of anesthesia. When pain greater than 3 on the visual analogue scale was reported, epidural rescue analgesia was administered.

Results

No epidural rescue anesthesia was required in 68.9% of the study group compared with 43.6% in the control group (p = 0.027).

Conclusions

Infiltration of the uterosacral ligaments with a long-acting local anesthetic in patients undergoing vaginal hysterectomy reduces the need for rescue analgesia, which is expensive and has adverse effects.     

Continuous wound infiltration system for postoperative pain management in gynecologic oncology patients

Purpose

Major open surgery for gynecologic cancer usually involves a long midline skin incision and induces severe postoperative surgical site pain (POSP) that may not be effectively controlled with the conventional management. We investigated whether combining a continuous wound infiltration system (CWIS, ON-Q PainBuster^®) and intravenous patient-controlled analgesia (IV PCA) effectively decreases POSP, compared with IV PCA alone, in gynecologic oncology patients.

Methods

This retrospective study included 62 Korean patients who received a long midline skin incision during gynecologic cancer surgery. The combined therapy group (n?=?31), which received CWIS (0.5% ropivacaine infused over 72 h) and IV PCA (fentanyl citrate), and the IV PCA only group (n?=?31) were determined using 1:1 matching. POSP was assessed using resting numeric rating scale (NRS) scores measured for 96 h after surgery, which were analyzed using a linear mixed model.

Results

The slopes of the predicted NRS values from the linear mixed model were significantly different between the groups. Compared with the control group, the combined therapy group had lower predicted NRS scores for the first 72 h, but higher predicted scores between 72 and 96 h. Moreover, the mean NRS scores over the first 48 h postoperation were significantly lower in the combined therapy group than in the control group; the scores were similar in both groups during the remaining period. With the exception of a higher body mass index in the CWIS group, the other variables, such as the dosage and usage time of fentanyl citrate, use of additional painkillers, and side effects, including wound complications, did not differ between groups.

Conclusions

Combined therapy using CWIS and IV PCA may be a useful strategy for POSP management in gynecologic oncology patients.

     

Clinical effects of gynecologic laparoscopy courses in the United Arab Emirates

Objective

To evaluate the impact of gynecologic laparoscopy courses on the participants’ laparoscopy practice.

Methods

We conducted 5 repeated laparoscopy courses between 2008 and 2012 at the United Arab Emirates University in Al Ain, United Arab Emirates, so as to enhance performance in the operating room. An electronic questionnaire was sent to all participants from each of the courses to evaluate the impact of course attendance on clinical practice.

Results

Of 70 participants who were approached to complete the online questionnaire, 38 (54.3%) responded. The majority were female (94.7%) and specialists (65.8%). Half the participants (50.0%) thought they would probably not have started performing laparoscopy without having attended the course. Of the participants, 18.4% thought that their operating skills had greatly improved, 63.2% felt that their operating skills had improved moderately to a lot, and 6/12 participants who had not been performing laparoscopy before attendance of the course began doing so. Overall, the course had no significant impact on the participants’ performance of laparoscopy (P = 0.51, McNemar test), but the proportion of participants who performed level II laparoscopy was significantly increased after course attendance (10.5% versus 47.4%; P = 0.001, McNemar test).

Conclusion

Gynecologic laparoscopy courses encourage gynecologists to use laparoscopy in clinical practice.     

Prevention of blood transfusion with intravenous iron in gynecologic cancer patients receiving platinum-based chemotherapy

Objectives

To compare the efficacy of intravenous iron and oral iron for prevention of blood transfusions in gynecologic cancer patients receiving platinum-based chemotherapy.

Materials and methods

Sixty-four non anemic gynecologic cancer patients receiving adjuvant platinum-based chemotherapy were stratified and randomized according to baseline hemoglobin levels and chemotherapy regimen. The study group received 200 mg of intravenous iron sucrose immediately after each chemotherapy infusion. The control group received oral ferrous fumarate at a dose of 200 mg three times a day. Complete blood count was monitored before each chemotherapy infusion. Blood transfusions were given if hemoglobin level was below 10 mg/dl.

Results

There were 32 patients in each group. No significant differences in baseline hemoglobin levels and baseline characteristics were demonstrated between both groups. Nine patients (28.1%) in the study group and 18 patients (56.3%) in the control group required blood transfusion through 6 cycles of chemotherapy (p = 0.02). Fewer median number of total packed red cell units were required in the study group compared to the control group (0 and 0.5 unit, respectively, p = 0.04). Serious adverse events and hypersensitivity reactions were not reported. However, constipation was significantly higher in the control group (3.1% and 40.6%, p = < 0.001).

Conclusions

Intravenous iron is an effective, well-tolerated treatment for primary prevention of blood transfusions in gynecologic cancer patients receiving platinum-based chemotherapy, associated with less constipation than the oral formulation.     

Comparative study of dexamethasone and ondansetron for prophylaxis of postoperative nausea and vomiting in laparoscopic gynecologic surgery

Objective

To compare intravenous dexamethasone and ondansetron for the prophylaxis of postoperative nausea and vomiting (PONV), a main complaint that affects almost 40%-75% of patients undergoing laparoscopic gynecologic surgery.

Methods

In a prospective study, 93 women were divided into 3 groups receiving 4 mg of dexamethasone, 8 mg of dexamethasone, or 4 mg of ondansetron. PONV score was used for assessment during the first 24 hours after surgery.

Results

The incidence of PONV during the 24-hour postoperative period was highest in the ondansetron group (61%). In the first 3 hours, the incidence of PONV in the ondansetron group was also higher: 51.6% as compared with 22.6% and 36.6% in the dexamethasone 4 mg and 8 mg groups, respectively. The overall incidence of PONV was highest in the first 3 hours as compared with later time periods, and there was a linear trend in decreasing PONV among the groups (P = 0.017). In the dexamethasone 4 mg group, the request for a rescue antiemetic was significantly lower: 0% as compared with 6.7% and 16.1% in the dexamethasone 8 mg and ondansetron 4 mg groups, respectively.

Conclusion

Dexamethasone was found to be an efficacious and cost-effective drug for the prophylaxis of PONV.     

Comparison of perioperative outcomes and cost of robotic-assisted laparoscopy,laparoscopy and laparotomy for endometrial cancer

Objective

To analyze the perioperative outcomes and cost of three surgical approaches in the treatment of endometrial cancer: robotic, laparoscopy and laparotomy.

Study design

We studied 347 patients with endometrial cancer treated in a single institution: 71 patients were operated by robotics, 84 by conventional laparoscopy and 192 by laparotomy. All patients underwent total hysterectomy, bilateral salpingoophorectomy and pelvic and para-aortic lymphadenectomy depending on the pathological features.

Results

Operative time was longer in the laparoscopy group as compared to robotics and laparotomy (218.2 min, 189.2 min, and 157.4 min respectively, p = 0.000). The estimated blood loss was lower in the robotic group relative to the other groups (99.4 ml in robotic, 190.0 ml in laparoscopy and 231.5 ml in laparotomy, p = 0.000). Similar findings were observed for the pre- and post-operative mean hemoglobin levels (−1.3 g/dl, −2.3 g/dl and −2.5 g/dl respectively, p = 0.000), and transfusion rate (4.2%, 7.1% and 14.1% respectively, p = 0.036). The length of hospital stay was higher in the laparotomy group compared to robotics and laparoscopy (8.1, 3.5 and 4.6 days respectively; p = 0.000). The conversion rate to laparotomy was lower for robotics (2.4% for robotics and 8.1% for laparoscopy, p = 0.181). Overall complications were similar for robotics and laparoscopy (21.1%, 28.5%) (p = 0.079). Robotic complications were significantly lower as compared to laparotomy (21.2 vs 34.9% (p = 0.036). No differences were found relative to disease-free or overall survival among the three groups. The global costs were similar for the three approaches (p = 0.566).

Conclusion

Robotics is a safe alternative to laparoscopy and laparotomy for endometrial cancer patients, offering improved perioperative outcomes and similar cost as compared to the other two surgical approaches.     

Does single-port access (SPA) laparoscopy mean reduced pain? A retrospective cohort analysis between SPA and conventional laparoscopy

Objective

To compare perioperative outcomes, including pain, between single-port access (SPA) and conventional laparoscopy in patients with presumed benign gynecological adnexal diseases.Study design A retrospective cohort study was performed at Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea. All operations in each group were performed consecutively by a single surgeon.

Results

A total of 188 patients were enrolled, with 94 patients per group. Baseline characteristics before surgery were similar between groups. Visual analogue scale pain scores 24 h after laparoscopy were lower in the SPA group than in the conventional laparoscopy group (2, 0–7 vs. 3, 2–6 P = 0.006). In addition, we found that the SPA group had less supplementary analgesic use (parenteral Ketoprofen intramuscular injection, 1 ampule = 100 mg) per patient after surgery compared to that in the conventional group (1 ampule, 0–7 vs. 2 ampule, 0–6, P = 0.010).

Conclusions

These results add to the evidence suggesting an advantage of SPA laparoscopy over conventional laparoscopy in terms of decreasing postoperative pain. Additional large, randomized controlled trials are needed to confirm these findings and to investigate long-term outcomes such as quality of life and cosmesis.     

A phase II trial of a surgical protocol to decrease the incidence of wound complications in obese gynecologic oncology patients

Objectives

Obese women have a high incidence of wound separation after gynecologic surgery. We explored the effect of a prospective care pathway on the incidence of wound complications.

Methods

Women with a body mass index (BMI) ≥ 30 kg/m² undergoing a gynecologic procedure by a gynecologic oncologist via a vertical abdominal incision were eligible. The surgical protocol required: skin and subcutaneous tissues to be incised using a scalpel or cutting electrocautery, fascial closure using #1 polydioxanone suture, placement of a 7 mm Jackson-Pratt drain below Camper's fascia, closure of Camper's fascia with 3-0 plain catgut suture and skin closure with staples.Wound complication was defined as the presence of either a wound infection or any separation. Demographic and perioperative data were analyzed using contingency tables. Univariable and multivariable regression models were used to identify predictors of wound complications. Patients were compared using a multivariable model to a historical group of obese patients to assess the efficacy of the care pathway.

Results

105 women were enrolled with a median BMI of 38.1. Overall, 39 (37%) had a wound complication. Women with a BMI of 30–39.9 kg/m² had a significantly lower risk of wound complication as compared to those with a BMI > 40 kg/m² (23% vs 59%, p < 0.001). After controlling for factors associated with wound complications the prospective care pathway was associated with a significantly decreased wound complication rate in women with BMI < 40 kg/m² (OR 0.40, 95% C.I.: 0.18–0.89).

Conclusion

This surgical protocol leads to a decreased rate of wound complications among women with a BMI of 30–39.9 kg/m².     

Cost of care using prophylactic negative pressure wound vacuum on closed laparotomy incisions

Objective

We wished to determine the reduction in the rate of wound complications that would render the use of prophylactic negative pressure wound vacuum therapy (NPWT) cost saving compared to routine incision care (RC) following laparotomy for gynecologic malignancy.

Methods

A decision tree was designed from a payer perspective to compare strategies for incision management following laparotomy for gynecologic malignancy: (1) RC; (2) prophylactic NPWT. Rates of wound complication, antibiotic use, re-hospitalization, re-operation, and home health use were obtained from a published cohort of 431 women who underwent laparotomy for endometrial cancer 2002–2007. Costs were estimated using Medicare reimbursements; cost of NPWT ($200) was obtained from hospital financial department. A 50% reduction in wound complications using NPWT was assigned initially and varied for sensitivity analysis.

Results

The mean BMI was 36. The wound complication rate was 31% (37% for BMI > 30, 41% for BMI > 40). The overall cost of incision care was $104 lower for NPWT than for RC. At the lowest cost of NPWT ($200), the risk of wound complication must be reduced by 33% (relative risk = 0.67) for NPWT to achieve cost savings in this cohort. Modeling obese and morbidly obese cohorts, the NPWT resulted in overall cost savings of $163 and $203, respectively, and the risk of wound complication must be reduced by 28% and 25%, respectively, for NPWT to achieve cost savings.

Conclusion

If the wound complication rate can be reduced by one-third, prophylactic NPWT is potentially cost saving in high-risk women undergoing laparotomy for gynecologic malignancy.     

Laparoscopy versus laparotomy in the management of ectopic pregnancy with massive hemoperitoneum

Objective

To compare the safety and feasibility of operative laparoscopy versus laparotomy in women with ruptured ectopic pregnancy and massive hemoperitoneum.

Methods

In a retrospective cohort study at a university-affiliated medical center, records of women with ruptured ectopic pregnancy and massive hemoperitoneum (> 800 mL) were reviewed.

Results

Sixty women were diagnosed with ruptured ectopic pregnancy and massive hemoperitoneum: 48 underwent emergency laparoscopy; 12 underwent emergency laparotomy. There was no difference in hemodynamic status at presentation between the groups. Median operating time was significantly shorter in the laparoscopy group (50 minutes [range, 43–63 minutes] vs 60 minutes [range, 60–72 minutes]; P = 0.01). Median intra-abdominal blood loss was significantly greater in the laparotomy group (1500 mL [range, 1400–2000 mL] vs 1000 mL [range, 800–1200 mL]; P = 0.002). There was no difference between the groups regarding treatment with blood products, perioperative complications, and hospitalization period.

Conclusion

In patients with ruptured ectopic pregnancy and massive hemoperitoneum, laparoscopy is feasible and safe, with significantly shorter operating times compared with laparotomy. While the mode of surgery should be based on the surgeon’s experience and preference, the significantly lower hemoperitoneum volume associated with laparoscopy may be a reflection of shorter operating times and quicker hemorrhage control.     

A randomized study comparing triptorelin or expectant management following conservative laparoscopic surgery for symptomatic stage III–IV endometriosis

Objective

To investigate the role of adjuvant treatment with gonadotropin-releasing-hormone agonist (GnRHa) following conservative surgical treatment of endometriosis.

Study design

Sixty patients in the reproductive age (mean age 28.6 years), with symptomatic stages III and IV endometriosis following laparoscopic surgery and without previous hormonal treatment were enrolled in a prospective, randomized, controlled trial to compare the effects of 3-month treatment with triptorelin depot—3.75 i.m. (30 patients) versus expectant management using placebo injection (30 patients).

Results

Six patients (one in triptorelin group and five in placebo group) were lost at follow-up, the remaining 54 were suitable for analysis. Pelvic pain persistence or recurrence, endometrioma relapses and pregnancy rate were evaluated during a 5-year follow-up. The results of 29 cases treated with triptorelin and 25 that received placebo did not show significant differences in pain recurrence (P = 1, RR = 0.94, 95% CI = 0.57–1.55), endometrioma relapse (P = 0.67, RR = 1.29, 95% CI = 0.66–2.50), and pregnancy rate in infertile women (P = 0.80, RR = 0.81, 95% CI = 0.37–1.80). Curves of time of pain recurrence and pregnancy during 5-year follow-up did not show significant differences between the two groups (P = 0.79 and P = 0.51, respectively, using Mantel–Haenzsel logrank test).

Conclusion

Triptorelin treatment after operative laparoscopy for stage III/IV endometriosis does not appear to be superior to expectant management in terms of prevention of symptoms recurrence and endometrioma relapse, and has no influence on pregnancy rate in endometriosis-associated infertility.     

Epidural analgesia is associated with an increased incidence of postoperative complications in patients requiring an abdominal hysterectomy for early stage endometrial cancer

Objective

Analgesia and early quality of recovery may be improved by epidural analgesia. We aimed to assess the effect of receiving epidural analgesia on surgical adverse events and quality of life after laparotomy for endometrial cancer.

Methods

Patients were enrolled in an international, multicentre, prospective randomised trial of outcomes for laparoscopic versus open surgical treatment for the management of apparent stage I endometrial cancer (LACE trial).The current analysis focussed on patients who received an open abdominal hysterectomy via vertical midline incision only (n = 257), examining outcomes in patients who did (n = 108) and did not (n = 149) receive epidural analgesia.

Results

Baseline characteristics were comparable between patients with or without epidural analgesia. More patients without epidural (34%) ceased opioid analgesia 3–5 days after surgery compared to patients who had an epidural (7%; p < 0.01). Postoperative complications (any grade) occurred in 86% of patients with and in 66% of patients without an epidural (p < 0.01) but there was no difference in serious adverse events (p = 0.19). Epidural analgesia was associated with increased length of stay (up to 48 days compared to up to 34 days in the non-epidural group). There was no difference in postoperative quality of life up to six months after surgery.

Conclusions

Epidural analgesia was associated with an increase in any, but not serious, postoperative complications and length of stay after abdominal hysterectomy. Randomised controlled trials are needed to examine the effect of epidural analgesia on surgical adverse events, especially as the present data do not support a quality of life benefit with epidural analgesia.     

Peritoneal fluid concentrations of β-chemokines in endometriosis

Objective

To examine whether the levels of MCP-1, RANTES and MCP-3 in the peritoneal fluid correlate with endometriosis.

Study design

Patients with endometriosis were compared with controls. Setting: Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT, USA. Subjects: This study involved 95 women of reproductive age who were undergoing laparoscopy for evaluation of infertility or for pelvic pain. They were divided into an endometriosis group (n = 54) and a control group (n = 41). Interventions: Peritoneal fluid samples were obtained and β-chemokines (MCP-1, RANTES and MCP-3) were measured using ELISA. Statistical analysis: Mean and median values were used to present values. Due to the non-normality of chemokines, a log transformation was applied. Differences were examined using independent samples t-test. One-way ANOVA and Tukey HSD multiple comparison post hoc tests were applied. A significance level at 0.05 was set.

Results

The levels of MCP-1 are higher (p for log values = 0.024) in the control group (mean = 687.6, SD = 467.7 pg/ml) than those of the endometriosis group (mean = 570.4, SD = 633.1 pg/ml). The same is true for the median values of MCP-1 (control median = 568.5, endometriosis median = 384.7 pg/ml). MCP-3 and RANTES do not differ significantly (MCP-3 p = 0.787, RANTES p = 0.153). The levels of MCP-1 in patients with stage II endometriosis are significantly lower in comparison with stage III (p = 0.048) and stage IV (p = 0.033) endometriosis.

Conclusions

A decrease in the concentrations of MCP-1 in stage I endometriosis has been observed, which is even larger in stage II, in contrast to stage III and stage IV endometriosis, which exhibit concentrations similar to the controls.     

Reproductive performance after conservative surgical treatment of postpartum hemorrhage

Objective

To evaluate the impact of bilateral internal iliac artery ligation (BIL), bilateral uterine artery ligation (BUAL), step-wise uterine devascularization (SWUD), and B-Lynch on infertility, ovarian reserve, and pregnancy outcome.

Methods

The study included 168 infertile or pregnant patients—recruited at outpatient clinics in Egypt—who had previously undergone uterine-sparing surgery (BIL [group I], n = 59; SWUD [group II], n = 65); BUAL [group III], n = 2; and B-Lynch [group IV], n = 42). One-way analysis of variance was used to compare the prevalence of infertility, the status of ovarian reserve, and the prevalence and type of relevant maternal and/or fetal obstetric complications between the groups.

Results

Groups II and IV had the highest prevalences of infertility. The ovarian reserve was significantly lower in group II. Unexplained infertility was the predominant cause of infertility in group I, anovulation and premature ovarian failure in group II, and endometriosis and intrauterine adhesions in group IV. The frequency of obstetric complications, particularly placenta previa and preterm labor, was high in group IV.

Conclusion

Of the 4 procedures, BIL had the least deleterious effect on reproductive performance; SWUD increased the risk of premature ovarian failure, and B-Lynch increased the risks of endometriosis, intrauterine adhesions, placenta previa, and preterm labor.     

A randomized controlled trial of uterine exteriorization versus in situ repair of the uterine incision during cesarean delivery

Objective

To compare extra-abdominal repair of the uterine incision at cesarean delivery with in situ repair.

Methods

The present study was a double-blind randomized controlled trial conducted at a university hospital in Egypt during 2012–2013, and included women with an indication for cesarean delivery. Extra-abdominal repair was used in group 1 (n = 500) and in situ repair in group 2 (n = 500). The primary outcome measure was the surgery duration.

Results

Surgery duration was significantly longer in group 1 than group 2 (49.9 ± 2.3 minutes vs 39.9 ± 1.8 minutes; P < 0.001). More patients in group 1 than in group 2 had postoperative moderate-to-severe pain (165 [33.0%] vs 115 [23.0%]; P = 0.001) and needed additional postoperative analgesia (100 [20.0%] vs 50 [10.0%]; P < 0.001). Moreover, mean time to bowel movement was longer in group 1 than in group 2 (17.0 ± 2.7 hours vs 14.0 ± 1.9 hours; P < 0.001).

Conclusion

In situ uterine closure is more advantageous than extra-abdominal repair in terms of surgery duration, postoperative pain and need for additional analgesia, and return of bowel movement.ClinicalTrials.gov:NCT01723605     

Physician pain and discomfort during minimally invasive gynecologic cancer surgery

Objective

Despite increasing awareness of physical strain to surgeons associated with minimally invasive surgery (MIS), its use continues to expand. We sought to gather information from gynecologic oncologists regarding physical discomfort due to MIS.

Methods

Anonymous surveys were e-mailed to 1279 Society of Gynecologic Oncology (SGO) members. Physical symptoms (numbness, pain, stiffness, and fatigue) and surgical and demographic factors were assessed. Univariate and multivariate analyses were performed to determine risk factors for physical symptoms.

Results

We analyzed responses of 350 SGO members who completed the survey and currently performed > 50% of procedures robotically (n = 122), laparoscopically (n = 67), or abdominally (n = 61). Sixty-one percent of members reported physical symptoms related to MIS. The rate of symptoms was higher in the robotic group (72%) than the laparoscopic (57%) or abdominal groups (49%) (p = 0.0052). Stiffness (p = 0.0373) and fatigue (p = 0.0125) were more common in the robotic group. Female sex (p < 0.0001), higher caseload (p = 0.0007), and academic practice (p = 0.0186) were associated with increased symptoms. On multivariate analysis, robotic surgery (odds ratio [OR] 2.38, 95% CI 1.20–4.69) and female sex (OR 4.20, 95% CI 2.13–8.29) were significant predictors of symptoms. There was no correlation between seeking treatment and surgical modality (laparotomy 11%, robotic 20%, laparoscopy 25%, p = 0.12).

Conclusions

Gynecologic oncologists report physical symptoms due to MIS at an alarming rate. Robotic surgery and female sex appear to be risk factors for physical discomfort. As we strive to improve patient outcomes and decrease patient morbidity with MIS, we must also work to improve the ergonomics of MIS for surgeons.     

Impact of post-radiation biopsies on development of fistulae in patients with cervical cancer

Objective

In the post-radiation patient, late vascular sequelae and fibrosis predispose women to poor tissue healing, such that small tissue injuries could theoretically evolve into much larger ones such as fistulae. We sought to determine if a correlation exists between invasive procedures such as post-treatment biopsies and the subsequent development of gynecologic fistulae.

Methods

A retrospective review was performed evaluating all patients treated for cervical cancer at our institution between 1997 and 2010. Biopsies or pelvic surgeries were included if performed within the radiated field, and evaluated in a multivariate predictive model for development of gynecologic fistulae.

Results

Out of 325 total patients, 27 patients with fistulae were identified (8.2%). 14 fistulae (51.9%) were considered toxicity-related, 6 (22.2%) resulted from primary disease, and 7 (25.9%) were attributable to recurrent disease. Eighty-nine patients underwent an invasive procedure (55 biopsies and 34 pelvic surgeries). Recurrent and/or residual cancer was found in 28 (31.5%) specimens, and of the 61 patients who underwent an invasive procedure and were not found to have evidence of recurrent disease, 9 (14.8%) subsequently developed a fistula at a median 3.08 months. An elevated dose of radiation to the rectum (OR 1.001 for dose > 72 Gy, p = 0.0005), advancing tumor stage (OR 5.38 for stage III, OR 10.47 for stage IV, p = 0.0288), and a post-radiation biopsy (OR 5.27, p = 0.013) were significantly associated with fistula development.

Conclusions

Performing a biopsy in an irradiated field is associated with a relatively low yield and significantly contributes to the risk for fistula development.     

Effect of spaced training with a box trainer on the acquisition and retention of basic laparoscopic skills

Objective

To investigate whether basic laparoscopic skills acquired via structured spaced training on a box trainer persist after 6 months.

Methods

In a prospective study undertaken at the Ege University School of Medicine (Izmir, Turkey) between January 1, 2012, and June 1, 2013, 22 gynecology residents without previous laparoscopy experience were randomly assigned (1:1) to receive training with a box trainer (1 hour per week for 4 weeks) or to a control group. At baseline and at 5 weeks, residents’ performance was assessed via the salpingectomy module of LapSim. The box trainer group was reassessed for skills retention 6 months later.

Results

The box trainer group performed significantly better than the control group in time (P = 0.01) and economy of movement (P = 0.001) at the final test. Error scores did not differ significantly. Deterioration between final and retention tests in the box trainer group were recorded in time (P = 0.041), instrument path length (P = 0.013), and instrument angular path (P = 0.075). However, time and economy of movement scores were better at the retention assessment than at baseline (P = 0.008 and P = 0.003, respectively).

Conclusion

Structured training with a box trainer improved laparoscopic skills, but deterioration was evident within 6 months. This deterioration should be considered when planning laparoscopic training programs.     

A comparison of primary intraperitoneal chemotherapy to consolidation intraperitoneal chemotherapy in optimally resected advanced ovarian cancer

Objective

To compare survival outcomes for patients with advanced epithelial ovarian cancer (EOC) who received primary intravenous/intraperitoneal (IV/IP) chemotherapy to those who received IV followed by consolidation (treatment given to patients in remission) IP chemotherapy.

Methods

Data were analyzed and compared for all patients with stage III–IV EOC who underwent optimal primary cytoreduction (residual disease ≤ 1 cm) followed by cisplatin-based consolidation IP chemotherapy (1/2001–12/2005) or primary IV/IP chemotherapy (1/2005–7/2011).

Results

We identified 224 patients; 62 (28%) received IV followed by consolidation IP chemotherapy and 162 (72%) received primary IV/IP chemotherapy. The primary IP group had significantly more patients with serous tumors. The consolidation IP group had a significantly greater median preoperative platelet count, CA-125, and amount of ascites. There were no differences in residual disease at the end of cytoreduction between both groups. The median progression-free survival (PFS) was greater for the primary IP group; however, this did not reach statistical significance (23.7 months vs 19.7 months; HR 0.78; 95% CI, 0.57–1.06; p = 0.11). The median overall survival (OS) was significantly greater for the primary IP group (78.8 months vs 57.5 months; HR 0.56; 95% CI, 0.38–0.83; p = 0.004). On multivariate analysis, after adjusting for confounders, the difference in PFS was not significant (HR 0.78; 95% CI, 0.56–1.11; p = 0.17), while the difference in OS remained significant (HR 0.59; 95% CI, 0.39–0.89; p = 0.01).

Conclusions

In our study, primary IV/IP chemotherapy was associated with improved OS compared to IV followed by consolidation IP chemotherapy in patients with optimally cytoreduced advanced EOC.