Intestinal surgery in gynecologic oncology

Intestinal surgery is frequently required in the management of patients with gynecologic malignancies. During a recent 3-year period 10.4% of all laparotomies performed on the Gynecology Service at Memorial Sloan-Kettering Cancer Center included major intestinal surgery. A total of 215 separate intestinal procedures were performed during 171 operations on 158 patients. The majority of operations were performed in patients with ovarian (42.7%), cervical (24%), and endometrial (12.3%) malignancies. Seventy-nine of 171 (46.2%) of operations were performed on previously irradiated patients. The most frequent indications for intestinal surgery were intestinal obstruction (43.2%) and intestinal fistula (21%). Procedures performed included 87 intestinal resections, 26 intestinal bypasses, 82 colostomies, and 20 intestinal conduit urinary diversions. Hand suturing was used in 71% of anastomoses; automatic stapling instruments were used in 29%. There was a single surgical mortality. Complications including infections, obstruction, and fistula formation were infrequent. These difficult intestinal procedures can be performed safely in the context of a fellowship training program. Since a significant proportion of all laparotomies done in gynecologic cancer patients will include major intestinal surgery, physicians managing patients with these diseases should have both the technical skills necessary to perform these procedures, as well as a thorough understanding of the diseases themselves.     

Laparoscopic surgery in gynecologic oncology

Panoramic retroperitoneal pelviscopy, introduced in 1987 was the first of the laparaoscopic operations used in the field of gyneceologic oncology. It was divised in order to enable the assessment of the pelvic lymph nodes prior to decision making in the management of patients with early cervical cancer. Starting from 1992, laparaoscopic surgery to all fields of gynecologic oncology and all the operations of the classical repertoire were transcribed in the new repertoire. This evolution is not without danger. Direct manipulation of an organ harboring a malignant tumor increases the chances of diffusion of malignant cells. Working with micro-instruments under CO(2) insufflation is likely to favor chances of dissemination. The true place of laparoscopic surgery is, as it has assuredly been since the beginning of its use, in the assessment of tumor surroundings and not in direct manipulation of the organ harboring the tumor. In the cases where imaging clearly shows regional and/or distal spread, it would be better to avoid laparoscopic dissection and retrieval. The most difficult problem in laparaoscopic onco-surgery is not the surgery itself, but in determining in which cases is can be used and in which it cannot.     

Outpatient surgery in gynecologic oncology.

During the review period, the literature on outpatient gynecologic oncology surgery has focused on two major management problems. The first questions the treatment of cervical dysplasia with local destruction and proposes that excisional biopsy using either the carbon dioxide laser or low voltage loop diathermy is a safe procedure in the outpatient setting with low morbidity and the advantage of histology to exclude microinvasion disease. However, long-term efficacy and complication rates need to be evaluated. The second raises the possibility of extending the role of the laparoscopist to include the management of all pelvic masses using new techniques. These articles represent the beginning of the discussion on the limits that exist (or should exist) in such surgery as many become highly facile endoscopists. Further studies will be needed to determine the necessary parameters to eliminate from this approach women who are at high risk of having a pelvic malignancy.     

Robotic surgery in the obese gynecologic patient

Despite robust interest in minimally invasive surgery for obese gynecologic patients, widespread use by gynecologic surgeons has been hindered by the technical difficulty of completing these procedures. The use of robotic assistance to overcome these challenges continues to increase. This study discusses the problem of obesity in the United States, provides basic definitions and calculations related to the disease, reviews some of the literature supporting laparoscopic surgery in obese patients, explores the emergence of robotics in this patient population, and offers "surgical pearls" to aid in the successful completion of minimally invasive robotic gynecologic procedures in heavier patients.     

Prevention of venous thromboembolism in gynecologic oncology surgery

Gynecologic oncology patients are at a high-risk of postoperative venous thromboembolism and these events are a source of major morbidity and mortality. Given the availability of prophylaxis regimens, a structured comprehensive plan for prophylaxis is necessary to care for this population. There are many prophylaxis strategies and pharmacologic agents available to the practicing gynecologic oncologist. Current venous thromboembolism prophylaxis strategies include mechanical prophylaxis, preoperative pharmacologic prophylaxis, postoperative pharmacologic prophylaxis and extended duration pharmacologic prophylaxis that the patient continues at home after hospital discharge. In this review, we will summarize the available pharmacologic prophylaxis agents and discuss currently used prophylaxis strategies. When available, evidence from the gynecologic oncology patient population will be highlighted.     

Postoperative delirium following radical gynecologic oncology surgery

The purpose of this study was to determine the incidence and possible predisposing factors for the development of postoperative delirum following radical gynecologic oncology surgery. A retrospective chart review was performed on 153 consecutive patients undergoing radical gynecologic oncology surgery. Preoperative variables assessed included: age, sepsis, decreased vision, decreased hearing, psychiatric history and abnormal mental status. Operative variables assess included: anesthesia time, estimated blood loss, hypotension, arrhythmia and transfusions. Preoperative medications, postoperative pain medication and abnormal perioperative laboratory values were also assessed. Sixteen of 150 patients (11%) developed postoperative delirium. Age was a significant predictor of postoperative delirium (median age 69 years vs 53 years, P = 0.006). Preoperative abnormal mental status examination was a significant predictor ( P = 0.27). Use of chronic narcotic pain medication was significant ( P = 0.008). All three patients who were septic at the time of emergency surgery developed postoperative delirum ( P = 0.001). No other variables could be identified. When reviewing the date using any high risk factor as a positive test (advanced age, sepsis, abnormal mental status exam or chronic narcotic pain medication), sensitivity was 88%, specificity 76%, positive predictive value 35% and negative predictive value 77%. Delirium occurred most frequently on the second post-operative day (range 1–4 days) and lasted for a median of 2 days (range 1–5 days). Delirium resolved completely in all 16 patients. In conclusion, 11% of women undergoing radical gynecologic oncology surgery developed postoperative delirium. Advanced age, preoperative abnormal mental status, chronic narcotic pain medication and preoperative sepsis were all predisposing risk factors.     

Cost-effectiveness of combination thromboembolism prophylaxis in gynecologic oncology surgery

OBJECTIVE: To compare the cost-effectiveness of external pneumatic compression devices with and without the addition of low-molecular-weight heparin for the prevention of deep vein thrombosis in high-risk surgical patients with gynecologic cancer. METHODS: A Markov decision analytic model was used to estimate the costs and outcomes associated with the prophylactic use of external pneumatic compression with and without low-molecular-weight heparin in patients undergoing gynecologic surgery. We estimated cost per fatal pulmonary embolus prevented, cost per deep vein thrombus prevented, and cost per life-year saved. Probability estimates for various outcomes and efficacies were obtained from the literature, using data specific for gynecologic surgery patients when available. RESULTS: In the base case scenario, cost-effectiveness estimates for combination prophylaxis varied from 10,091 dollars per life-year saved for a 35-year-old patient with IB cervix cancer patient to 50,181 dollars for a 65-year-old patient with stage IIIC ovarian cancer, costs within the 50,000-65,000 dollars per life-year saved threshold considered to be cost-effective. Combination prophylaxis appeared to be cost-effective in gynecologic oncology patients as long as the risk of perioperative thromboembolism using this method of prevention was less than or equal to 4%. Sensitivity analysis indicated that variation of the marginal cost of low-molecular-weight heparin and the marginal effectiveness to extremes did not change the conclusions of the statistical model. CONCLUSION: The use of combination therapy external pneumatic compression is estimated to be cost-effective for high-risk gynecologic oncology patients undergoing surgery. Clinical trials to determine the efficacy of perioperative combination therapy in gynecologic surgery are justified.     

Pulmonary embolism after major abdominal surgery in gynecologic oncology

OBJECTIVE: To estimate the incidence and prognostic significance of postoperative pulmonary embolism after gynecologic oncology surgery. METHODS: All patients who underwent gynecologic oncology surgery from June 2001 to June 2003 and received venous thromboembolism prophylaxis with only intermittent pneumatic compression and early ambulation were identified from our database. Patients were grouped by procedure (major/minor abdominal or nonabdominal surgery), diagnosis (malignant/nonmalignant), and cancer subtype. Groups were compared by chi2 analysis and logistic regression. Survival was studied with the Kaplan-Meier method and Mantel-Byar test. RESULTS: A total of 1,373 surgical patients were identified over the 2-year period, including 839 major abdominal surgery cases and 534 minor abdominal surgery or nonabdominal surgery cases. Of the 839 patients, 507 had a diagnosis of cancer, and 332 were benign. The incidence of pulmonary embolism among cancer patients undergoing major abdominal surgery was 4.1% (21/507) compared with 0.3% (1/332) among patients undergoing major abdominal surgery with benign findings (P < .001, odds ratio [OR] 13.8, 95% confidence interval [CI] 1.9-102.1). The incidence of pulmonary embolism among patients undergoing minor/nonabdominal surgery was 0.4% (2/536). Cancer diagnosis and age more than 60 years were identified as risk factors for pulmonary embolism (P = .009, OR 0.31, 95% CI 0.13-0.74). One-year survival for patients with and those without pulmonary embolism were 48.0% +/- 12% and 77.0% +/- 2%, respectively. CONCLUSION: Patients with cancer undergoing major abdominal surgery and using pneumatic compression for thromboembolic prophylaxis had a 14-fold greater odds of developing a pulmonary embolism compared with patients with benign disease. Randomized studies are needed to determine whether additional prophylactic measures may benefit this high-risk group of patients. LEVEL OF EVIDENCE: II-3.     

Feasibility of same-day discharge after laparoscopic surgery in gynecologic oncology

Objectives

To characterize the post-operative care of BRCA1 and BRCA2 mutation carriers who undergo risk-reducing salpingo-oophorectomy (RRSO).

Methods

BRCA1 and BRCA2 mutation carriers from our Cancer Risk Program who elected RRSO were sent questionnaires regarding their post-surgical surveillance and treatment for menopause symptoms, primary peritoneal cancer and bone loss.

Results

In 51 mutation carriers who were surveyed a median of 6 years after RRSO, 24 (47%) received dual-energy X-ray absorptiometry (DXA) testing, yearly CA-125 serum testing and yearly pelvic examination. Three women received none of these examinations in follow-up. Respondents reported an average of 3.5 menopausal symptoms (range 0-9). The mean number of menopausal symptoms reported by respondents using HRT was 2.8, compared to 3.9 symptoms reported by women not using HRT (p = 0.06). Six of 10 (60%) subjects who reported no history of DXA bone scan, and 10 of 15 (67%) subjects who reported no post-surgical CA-125 serum monitoring noted that their physicians “did not recommend” testing. Two out of six symptomatic women who were younger than 50 (33%) who had no other contraindication to the use of HRT reported their non-use was because their care providers “advised against” HRT use.

Conclusion

We believe that the lack of post-RRSO health care guidelines has resulted in inconsistent care for this cohort of patients. We proposed that national guidelines be developed to standardize care with the goal of optimizing long term survival in this unique cohort of young cancer previvors.     

Cost-effectiveness of deep venous thrombosis prophylaxis in gynecologic oncology surgery

OBJECTIVE: To estimate the cost-effectiveness of preventive strategies for deep vein thrombosis (DVT) in patients undergoing surgery for gynecologic cancer. METHODS: A model was constructed to estimate the costs and outcomes associated with the use of external pneumatic compression, unfractionated heparin, and low molecular weight heparin in women with cervical, endometrial, and ovarian cancer. We estimated cost per DVT prevented, per fatal pulmonary embolus (PE) prevented, and per life-year saved. Probability estimates for various outcomes and efficacies were obtained from the literature, using data specific for gynecologic patients when available. RESULTS: Cost-effectiveness estimates ranged from $27 per life-year saved for a 55-year-old endometrial cancer patient to $5132 per life-year saved for a 65-year-old with ovarian cancer. Although low molecular weight heparin and unfractionated heparin were cost-effective compared with no prophylaxis, each was less effective than external pneumatic compression in the base case. The results of the analysis were sensitive to assumptions about the relative risk of DVT, the life expectancy of the patient, the costs of future treatment, and the relative effectiveness of the different strategies: If unfractionated heparin or low molecular weight heparin is at least 2-3% more effective than external pneumatic compression, then the incremental cost per life-year of either would be less than $50,000 compared with external pneumatic compression. CONCLUSION: Prophylaxis of DVT is cost-effective in terms of life-years gained even for patients with relatively short life expectancies, such as ovarian cancer patients. External pneumatic compression appears to be the most cost-effective strategy under our baseline assumptions, but further studies in gynecologic cancer are needed to validate our conclusions.     

Screening in gynecologic oncology

Practical value of screening depends on various characteristics of cancers themselves, suitable tests and programs being able to cover a sufficient part of the population. Cancers favourable for screening are those with a high prevalence in the population screened, a detectable preclinical stage and better treatment results if detected by screening than detected by symptoms. Suitable screening tests have to be highly sensitive and specific, simple, cheap and without any risk. Before the widespread application of a screening program as a public health measure scientific basis and rational organization should be well known and the benefit has to be evident. Cytological screening is the most effective measure in cervical cancer control. Screening also promises a reduction in mortality from breast cancer, but further evaluation is necessary before decisions can be made about the application as a public health measure. Selective screening is probably connected with an improved health care for high risk persons of endometrial cancer. Follow up with HCG-RIA after hydatidiform mole improves early detection and prognosis of trophoblastic neoplasias significantly.     

Successful incorporation of robotic surgery into gynecologic oncology fellowship training

Background

The increasing role of robotic surgery in gynecologic oncology may impact fellowship training. The purpose of this study was to review the proportion of robotic procedures performed by fellows at the console, and compare operative times and lymph node yields to faculty surgeons.

Methods

A prospective database of women undergoing robotic gynecologic surgery has been maintained since 2008. Intra-operative datasheets completed include surgical times and primary surgeon at the console. Operative times were compared between faculty and fellows for simple hysterectomy (SH), bilateral salpingo-oophorectomy (BSO), pelvic (PLND) and paraaortic lymph node dissection (PALND) and vaginal cuff closure (VCC). Lymph nodes counts were also compared.

Results

Times were recorded for 239 SH, 43 BSOs, 105 right PLNDs, 104 left PLNDs, 34 PALND and 269 VCC. Comparing 2008 to 2011, procedures performed by the fellow significantly increased; SH 16% to 83% (p < 0.001), BSO 7% to 75% (p = 0.005), right PLND 4% to 44% (p < 0.001), left PLND 0% to 56% (p < 0.001), and VCC 59% to 82% (p = 0.024). Console times (min) were similar for SH (60 vs. 63, p = 0.73), BSO (48 vs. 43, p = 0.55), and VCC (20 vs. 22, p = 0.26). Faculty times (min) were shorter for PLND (right 26 vs. 30, p = 0.04, left 23 vs. 27, p = 0.02). Nodal counts were not significantly different (right 7 vs. 8, p = 0.17 or left 7 vs. 7, p = 0.87).

Conclusions

Robotic surgery can be successfully incorporated into gynecologic oncology fellowship training. With increased exposure to robotic surgery, fellows had similar operative times and lymph node yields as faculty surgeons.     

Thromboembolism in gynecologic oncology.

The risk of thrombo-embolic complications increases in surgical gynaecological oncology as a consequence of difficult and long-lasting interventions. In gynaecologic operations without any drug prophylaxis thrombosis has been reported by 24-29%, whereas in operations of progressed oncological findings thrombo-embolic complications arise in almost every second case. Such complications have to be taken seriously due to difficulty treatable sequelae (post-thrombic syndrome) and due to potentially lethal pulmonary embolism. Furthermore, they are important causes of postoperative early mortality. Diagnosis of a deep thrombosis is insecure even for experienced clinicians. We have various diagnostical means at our disposal, such as phlebography, sounding and 125-iodine-fibrinogen-testing. Differentiated drug medication for the prevention and therapy of thrombo-embolism is definitely indicated. There are also different kinds of physical and drug-aided means, which can be applied according to the individual situation.