Approaches to Morbidly Obese Women with Gynecologic Cancer

Modifiable lifestyle factors, such as obesity, contribute significantly to cancer and preventable death worldwide. This review appraises recent evidence on the relationship of obesity with endometrial cancer, ovarian cancer, and other gynecologic malignancies as well as new evidence for the best surgical and medical practices in morbidly obese female cancer patients, including utilization of minimally invasive surgery, cytoreductive surgery, appropriate chemotherapy dosing, and optimizing radiation therapy in this population. For gynecologic cancer survivors, physical activity and weight loss are associated with improved health and quality of life. Interventional trials show promise in increasing physical activity and weight loss. Women’s cancer care providers should integrate counseling about obesity in the management of survivors of gynecologic cancers.     

Panniculectomy with Simultaneous Gynecologic Oncology Surgery

OBJECTIVE: The objective was to report the utility and morbidity of panniculectomy in obese gynecologic oncology patients undergoing exploratory laparotomy. METHODS: A retrospective chart review of 41 consecutive women who had a panniculectomy as part of an abdominal gynecologic oncology procedure between July 1996 and May 2000 was performed. Obese patients possessing a large pannus, the majority with a BMI > or = 30 kg/m(2), were included. Demographic, preoperative, operative, and postoperative data were obtained. Statistical analyses were performed using Statistical Analysis System (SAS) Version 6.13. RESULTS: Panniculectomy was performed on 41 patients with a mean age of 55, weight of 126 kg, and BMI of 48 kg/m(2). The most common comorbidities in this population were hypertension, diabetes, and osteoarthritis. Wound infection occurred in 4 (9.8%) patients; 88% of the patients received a hysterectomy. The average EBL was 358 cc. Operative time and length of hospital stay were on average 203 min and 5.5 days, respectively. A prior history of diabetes increased the risk of early complications (P = 0.03). Late complications were more likely to occur in older women (P = 0.05). Wound complications were increased in patients with larger BMI's (P = 0.05). CONCLUSIONS: This study supports the safety of the panniculectomy procedure in this high-risk group of morbidly obese patients for whom a technical advantage may be achieved by improved operative exposure.     

Robotic Surgery in Elderly and Very Elderly Gynecologic Cancer Patients

Study Objective

To investigate the feasibility, safety, and short-term outcomes of robotic surgery (RS) for gynecologic oncologic indications (cervical, endometrial, and ovarian cancer) in elderly patients, especially women age 65 to 74 years (elderly group [EG]) compared with women age ≥75 years (very elderly group [VEG]).

Cancer Risk-Reducing Opportunities in Gynecologic Surgery

This review article discusses cancer risk-reducing opportunities in gynecologic surgery. We cover strategies to reduce ovarian and uterine cancer risk by presenting general practice guidelines and expanding on the literature behind clinical decision points. We address populations of women at increased hereditary risk and those at population risk. We specifically discuss risk-reducing salpingo-oophorectomy, prophylactic salpingectomy with delayed oophorectomy, concomitant hysterectomy, opportunistic salpingectomy, bilateral tubal ligation, and hysterectomy. For clinical scenarios in which data are limited or conflicting, we detail the studies on which clinicians' decisions hinge to allow the reader to weigh the available evidence.     

Fertility Sparing Surgery in Gynecologic Cancer

Fertility preservation is one of the major concerns of young patients diagnosed with gynecological cancer. With newer treatment regimens and better surgical techniques, survival rates after cancer treatment have improved, hence preservation of fertility has recently become an important issue in the treatment of gynecological cancers. Fertility sparing surgery may be an option for early-stage cervical cancer with the development of loop excision techniques and radical trachelectomy which allows a radical approach to cervix cancer at the same time preserving the uterus and thus fertility. Fertility preservation is possible in Stage 1 epithelial ovarian cancers, germ cell ovarian tumors, and borderline cancers. Hormonal therapy with progestin agents is effective in early endometrial cancer. In patients desiring future pregnancy, fertility sparing options must be explored before starting treatment for gynecologic cancers.     

Early Effect of Bariatric Surgery on Urogenital Function in Morbidly Obese Men

IntroductionObesity is an independent risk factor for erectile dysfunction (ED) and lower urinary tract symptoms (LUTS). Bariatric surgery has been shown to improve erectile function and urinary symptoms in medium- to long-term studies (3- to 12-month postoperative follow-up).AimTo investigate the early effect (1 month postoperatively) of bariatric surgery on ED and LUTS, which has not previously been investigated.MethodsMorbidly obese men (body mass index > 35 kg/m²) undergoing bariatric surgery were asked to complete the International Index of Erectile Function (IIEF) and International Prostate Symptom Score (IPSS) questionnaires before surgery and 1, 3, and 6 months after surgery.Main Outcome MeasureThe influence of bariatric surgery on urogenital function, body mass index, fasting blood glucose, and glycated hemoglobin were analyzed using parametric and non-parametric tests for paired samples.ResultsOf 30 patients who completed the study, 18 reported ED (IIEF score < 25) and 14 reported moderate or severe LUTS (IPSS ≥ 8) before the operation. Twelve patients had ED and moderate or severe LUTS. IIEF score, IPSS, body mass index, percentage of weight loss, fasting blood glucose, and glycated hemoglobin showed significant and rapid improvement after bariatric surgery starting at the 1-month postoperative time point and improvement continued throughout the study in all patients with ED or moderate to severe LUTS.ConclusionThis is the first study showing improvement in erectile and urinary function within 1 month after bariatric surgery, an effect that was parallel to glycemic improvement and weight loss.     

Percutaneous Abscess Drainage in Gynecologic Cancer Patients

Percutaneous abscess drainage (PAD) is regarded as an alternative treatment for the care of the gynecologic cancer patient with a pelvic infection. Four female patients with infected pelvic malignancies were evaluated and treated with PAD at Thomas Jefferson University Hospital over a 4-year period. Abscesses in three of the four patients were drained successfully and the catheters were ultimately removed. Successful drainage was defined as a good clinical response and avoidance of surgical debridement. For the patient with an infected pelvic malignancy, PAD offers an alternative to surgery without associated morbidity. Our experience indicates PAD is associated with expedient clinical recovery and preservation of quality of life for most patients.     

Laparoscopy in the Morbidly Obese: Physiologic Considerations and Surgical Techniques to Optimize Success

The objectives of this review were to analyze the literature describing the benefits of minimally invasive gynecologic surgery in obese women, to examine the physiologic considerations associated with obesity, and to describe surgical techniques that will enable surgeons to perform laparoscopy and robotic surgery successfully in obese patients. The Medline database was reviewed for all articles published in the English language between 1993 and 2013 containing the search terms “gynecologic laparoscopy” “laparoscopy,” “minimally invasive surgery and obesity,” “obesity,” and “robotic surgery.” The incidence of obesity is increasing in the United States, and in particular morbid obesity in women. Obesity is associated with a wide range of comorbid conditions that may affect perioperative outcomes including hypertension, atherosclerosis, angina, obstructive sleep apnea, and diabetes mellitus. In obese patients, laparoscopy or robotic surgery, compared with laparotomy, is associated with a shorter hospital stay, less postoperative pain, and fewer wound complications. Specific intra-abdominal access and trocar positioning techniques, as well as anesthetic maneuvers, improve the likelihood of success of laparoscopy in women with central adiposity. Performing gynecologic laparoscopy in the morbidly obese is no longer rare. Increases in the heaviest weight categories involve changes in clinical practice patterns. With comprehensive and thoughtful preoperative and surgical planning, minimally invasive gynecologic surgery may be performed safely and is of particular benefit in obese patients.     

Witzel Gastrostomy in Gynecologic Surgery

Tube gastrostomy is a well-accepted procedure for gastrointestinal decompression and the relief of small bowel obstruction. The Witzel technique was used in 123 patients undergoing pelvic–abdominal surgery for known or suspected gynecologic malignancy or for clinical bowel obstruction. For 115 patients, the tube remained in place from 3 to 18 days (mean, 8 days). Eight patients were discharged from the hospital with the tube in place, and these functioned successfully from 43 to 136 days. Sixteen patients (13%) had complications, but there was neither long-term morbidity nor mortality associated with the tube. Witzel gastrostomy, using a Foley catheter, is easily learned, inexpensive, and has an acceptable complication rate. When the need for long-term gastrointestinal decompression is anticipated, Witzel gastrostomy is preferred to nasogastric tube suctioning to facilitate patient care and comfort.     

Incidence of Complications during Gynecologic Laparoscopic Surgery in Patients after Previous Laparotomy

Study ObjectiveTo estimate the incidence of complications arising during gynecologic laparoscopic surgery in patients who have undergone previous abdominal surgeries and to assess predictable factors associated with complications based on the characteristics of the previous laparotomy.DesignRetrospective study (Canadian Task Force classification II–2).SettingUniversity-affiliated hospital.PatientsWe enrolled 307 patients with a history of laparotomy who underwent laparoscopic surgery at our hospital between January 2002 and June 2009.InterventionsThe closed primary approach via either the ninth intercostal space or the posterior vaginal fornix was used to avert bowel injury. Complications were defined as organ injury that required repair during surgery and immediate conversion to laparotomy because of technical difficulties. Factors influencing complications during laparoscopic surgery were analyzed using logistic regression.Measurements and Main ResultsNo complications developed during primary entry. Adhesiolysis was required in 195 areas of adhesion in 146 patients before laparoscopic surgery could proceed. These areas comprised 45 (14.7%) and 31 (10.1%) abdominal wall adhesions without and within the umbilicus, respectively, and 119 (38.8%) with intrapelvic adhesions. Complications in 41 patients (13.4%) included bowel damage (n = 35), urinary system damage (n = 4), and conversion to laparotomy because of technical difficulties (n = 2). Overall, 38 complications were laparoscopically repaired, and 1 complication was repaired at minilaparotomy. Intrapelvic adhesions were found in all patients with complications, and bowel adherent to the intrapelvis was identified in 38 of these (92.7%). The most significant predictive factors positively associated with development of complications according to logistic regression analysis were a history of abdominal myomectomy (odds ratio, 6.27; 95% confidence interval, 2.95–13.38; p <.001) and excisional endometriosis surgery (odds ratio, 5.80; 95% confidence interval, 2.08–16.13; p = .001). No patients developed severe delayed complications after surgery.ConclusionOur findings suggest that potential predictive factors of complications are a history of abdominal myomectomy and excisional endometriosis surgery performed because of intrapelvic adhesions.     

Gastrostomy Using a “Gastrofix” as an Alternative for Nasogastric Tubes in Ovarian Cancer Surgery

Objective.The aim of this study was to evaluate the use of a gastrostomy instead of a nasogastric tube following surgery for advanced ovarian cancer.Design.This was a retrospective observational study.Setting.The study was performed in a university teaching hospital.Participants.Thirty-four women undergoing debulking surgery for ovarian carcinoma participated.Methods.In order to increase patients' comfort during the first postoperative days we inserted for gastric decompression a transcutaneous instead of a transnasal tube following debulking surgery. Only patients with bowel involvement and/or extensive tumor load in the upper abdomen were included in the study. In this study we report on the use of a gastrostomy using a Cystofix drainage catheter, resulting in what we call a “Gastrofix.” The Gastrofix was placed in 34 patients with ovarian cancer. In 32 (94%) patients an extraperitoneal hysterectomy and bilateral salpingo-oophorectomy was performed, in 16 (47%) a resection of the diaphragmatic peritoneum, in 14 (41%) patients a paraaortic lymphadenectomy, and in 12 (35%) patients part of the bowel was resected.Results.Free oral liquid intake and poor fiber diet were started after 5.5 days (median, range from 3–8 days) and 8 days (median, range from 4–12 days), respectively. The catheter was clamped off after 5 days (median, range from 2–8 days) and removed after 7 days (median, range from 3–11 days). Of the 34 patients only 12 (35%) received antiemetics (median of 4 days, range from 1–7 days). In 1 patient (3%) pain at the insertion site was observed on the third and fourth postoperative days. In 3 patients (9%) some fluid leakage at the insertion site was noted. In 4 patients (12%) the catheter fell out prematurely on days 0, 4, 6, and 9, respectively. In none of the patients were infection or fistulas at the insertion site noted. In all patients there was a satisfactory drainage of gastric content.Conclusion.After debulking surgery, the use of a Gastrofix resulted in an adequate gastrointestinal decompression without major complications. This technique may increase the comfort of the patient during the postoperative phase considerably.     

Special Needs Related to the Pain and Discomfort of Patients With Gynecologic Cancer

Patients with gynecologic malignancies can experience pain associated with a variety of causes. Chronic pain associated with the disease or treatment presents the most problems. Chronic cancer-related pain is associated with negative mood states and a decrease in the patient's quality of life. Clinicians must conduct pain assessments on a routine basis to accurately diagnose the specific pain syndrome in patients with gynecologic cancer. An overview of how to conduct a pain assessment with such patients is provided. The etiology, clinical manifestations, and treatment strategies for the most common pain syndromes seen in patients with gynecologic cancer are reviewed. The use of nonpharmacologic interventions with this patient population is discussed.     

预防性抗凝治疗在妇科恶性肿瘤中的应用

恶性肿瘤通过多种机制激活凝血系统,引起高凝状态。高凝状态也能促进肿瘤细胞的增殖和转移。高凝状态易形成静脉血栓栓塞(venous thromboembolism,VTE),VTE是恶性肿瘤常见的并发症,能直接导致患者死亡。妇科恶性肿瘤患者是发生VTE的高危人群。VTE是影响肿瘤患者生存率的重要因素。目前,临床指南推荐传统开腹手术患者术后立即进行最长达28 d的预防性抗凝治疗。对于进行微创手术的妇科肿瘤患者和术后进行化疗的患者,是否常规进行预防性抗凝治疗存在争议,仍需根据患者具体情况进行综合分析。肝素具有一定的抗肿瘤作用,但长期使用预防性抗凝治疗对恶性肿瘤患者预后的影响仍待进一步研究。     

Laparoscopy and Body Mass Index: Feasibility and Outcome in Obese Patients Treated for Gynecologic Diseases

Study ObjectiveTo compare feasibility and surgical outcome of laparoscopic gynecologic surgery between obese, overweight, normal-weight, and underweight women.DesignRetrospective case control study (Canadian Task Force classification II-3).SettingSurgery Unit of Minimally Invasive Gynaecology.PatientsA total of 503 women who underwent laparoscopic procedures for both benign disease and malignancies.InterventionsFour main categories of gynecologic disease were identified: uterine fibroids, benign adnexal masses, endometriosis, and endometrial cancer (stage I). For each category patients were divided into 4 groups: underweight (BMI <18.5 kg/m²), normal-weight (BMI 18.5–24.9 kg/m²), overweight (BMI 25–29.9 kg/m²), and obese (BMI ≥30 kg/m²).Measurements and Main ResultsSelected outcomes were duration of surgery, rate of laparotomy conversion, intraoperative and postoperative complications, and duration of hospital stay. No statistical difference regarding demographic data, surgical and medical history, and intraoperative findings was present between groups. No laparotomy conversion occurred. Regarding duration of surgery, we found no statistical difference among the BMI groups with regard to benign diseases, whereas pelvic lymphadenectomy in obese patients with endometrial cancer had a statistically significant longer duration than in the control group (122 ± 47min vs 65 ± 21 min, p <.001). The postoperative complication rate was 0.01%: 3 cases of blood transfusion and 1 case of hemoperitoneum among myomectomies; 1 ureteral fistula in surgery for pelvic endometriosis; and 1 case of postoperative lymphocele in endometrial cancer group. No statistically significant difference was found in duration of hospital stay among the BMI groups in any of the categories of disease. For each category we conducted an analysis to identify any possible risk factors other than BMI in the surgical outcomes.ConclusionLaparoscopic approach in the various applications of gynecologic surgery does not appear to be significantly influenced by BMI in terms of surgical outcomes, laparotomy conversion rate, intraoperative and postoperative complications rate, and duration of hospital stay. The technical difficulties can be solved if skilled surgeons and anesthetists are available.     

Massive Pelvic Hemorrhage during Gynecologic Cancer Surgery: “Pack and Go Back”

Over a 13-year period, intraabdominal packing has been used to control massive hemorrhage during surgery for gynecologic malignancy in six patients. Five patients had undergone total pelvic exenteration and one total abdominal hysterectomy with bilateral salpingo-oophorectomy for endometrial cancer. Massive hemorrhage was defined as infusion of more than 10 units of blood and replacement of more than one total blood volume. Tamponade was performed using continuous Kerlex rolls (Kendall Co., Boston, MA) in a bowel bag with directed pressure over the hemorrhaging site with abdominal closure. The packs were removed in 48 to 72 hr in the operating room, transabdominally in five patients and transvaginally in one. One postoperative death occurred within 8 hr of surgery. The packing was ultimately successful in the five remaining patients. In five of six patients, tumors were removed before the packing, whereas in one, the tumor was removed concurrently with the pack. In one patient, immediate repacking was required after pack removal, with ultimate hemostasis. Morbidity included “empty pelvis syndrome” in four patients, neuropathy in three (obturator in 1, sciatic in 2), and small bowel obstruction in one. In patients with severe intraoperative hemorrhage, intraabdominal packing has been succesful as a mode of treatment.