Postoperative Intestinal Fistula in Primary Advanced Ovarian Cancer Surgery

Background

Advanced ovarian cancer (AOC) requires an aggressive surgery with large visceral resections in order to achieve an optimal or complete cytoreduction and increase the patient’s survival. However, the surgical aggressiveness in the treatment of AOC is not exempt from major complications, such as the gastrointestinal fistula (GIF), which stands out among others due to its high morbidity and mortality.

Methods

We evaluated the clinicopathological features in patients with AOC and their association with GI. Data for 107 patients with AOC who underwent primary debulking surgery were analyzed retrospectively. Clinicopathological features, including demographic, surgical procedures and follow-up data, were analyzed in relation to GIF.

Results

GIF was present in 11% of patients in the study, 5 (4.5%) and 7 (6.4%) of colorectal and small bowel origin, respectively. GIF was significantly associated with peritoneal cancer index (PCI) >20, more than 2 visceral resections, and multiple digestive resections. Overall and disease-free survival were also associated with GIF. Multivariate analysis identified partial bowel obstruction and operative bleeding as independent prognostic factors for survival. The presence of GIF is positively associated with poor prognosis in patients with AOC.

Conclusion

Given the importance of successful cytoreductive surgery in AOC, the assessment of the amount of tumor and the aggressiveness of the surgery to avoid the occurrence of GIF become a priority in patients with AOC.

Outcome quality standards in advanced ovarian cancer surgery

INTRODUCTION

Advanced ovarian cancer surgery (AOCS) frequently results in serious postoperative complications. Because managing AOCS is difficult, some standards need to be established that allow surgeons to assess the quality of treatment provided and consider what aspects should improve. This study aimed to identify quality indicators (QIs) of clinical relevance and to establish their acceptable quality limits (i.e., standard) in AOCS.

MATERIALS AND METHODS

We performed a systematic search on clinical practice guidelines, consensus conferences, and reviews on the outcome and quality of AOCS to identify which QIs have clinical relevance in AOCS. We then searched the literature (from January 2006 to December 2018) for each QI in combination with the keywords of advanced ovarian cancer, surgery, outcome, and oncology. Standards for each QI were determined by statistical process control techniques. The acceptable quality limits for each QI were defined as being within the limits of the 99.8% interval, which indicated a favorable outcome.

RESULTS

A total of 38 studies were included. The QIs selected for AOCS were complete removal of the tumor upon visual inspection (complete cytoreductive surgery), a residual tumor of < 1 cm (optimal cytoreductive surgery), a residual tumor of > 1 cm (suboptimal cytoreductive surgery), major morbidity, and 5-year survival. The rates of complete cytoreductive surgery, optimal cytoreductive surgery, suboptimal cytoreductive surgery, morbidity, and 5-year survival had quality limits of < 27%, < 23%, > 39%, > 33%, and < 27%, respectively.

CONCLUSION

Our results provide a general view of clinical indicators for AOCS. Acceptable quality limits that can be considered as standards were established.

Evaluation of the relationship between lactacidemia and postoperative complications after surgery for peritoneal carcinomatosis

Background

Cytoreductive surgery was developed as a treatment for peritoneal carcinomatosis. However, this surgery is associated with important complications. The present study aimed to assess the relationship between lactacidemia and the rate of associated complications during the immediate postoperative period in the intensive care unit (ICU) in patients undergoing cytoreductive surgery.

Methods

This was a retrospective observational study. A total of 57 patients underwent cytoreductive surgery. All patients were admitted to the ICU immediately after the surgery. Data on lactic acid levels at the time of admission and discharge from the ICU were collected. Postsurgical complications that occurred during the ICU stay were recorded according to failure-to-rescue analysis and their severity stratified according to the Clavien-Dindo classification.

Results

The lactic acid levels at admission to the ICU were significantly higher in patients who developed complications, with an almost tripled unadjusted relative risk (2.9, 95% CI: 1.6, 5.3), than in those who did not develop complications for the lactacidemia threshold established in the cumulative sum curve graphs. After adjustment for confounding effects, the relative risk became even higher (3.1, 95% CI: 1.8, 3.6). Lactic acid levels were still significantly higher in this group at the time of discharge from the ICU.

Conclusions

Serum lactate level is a risk factor for postoperative complications in patients undergoing cytoreductive surgery for peritoneal carcinomatosis. This study suggests that the risk of developing severe complications almost triples with a lactic acid level of 2.5 mmol/L or higher at the time of admission in the ICU.

Use of negative pressure wound therapy after infection and flap dehiscence in radical vulvectomy: A case report

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Radical vulvectomy is a very agressive surgery.

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Deshiscence of vulvar wound is one of the most feared complications.

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Negative wound pressure therapy could be incorporate in the management of this complications.

Introduction

Vulvar cancer has a lower incidence in high income countries, but is rising, in part, due to the high life expectancy in these societies. Radical vulvectomy is still the standard treatment in initial stages. Wound dehiscence contitututes one of the most common postoperative complications.

Presentation of case

A 76 year old patient with a squamous cell carcinoma of the vulva, FIGO staged, IIIb is presented. Radical vulvectomy and bilateral inguinal lymph node dissection with lotus petal flaps reconstruction are performed as the first treatment. Wound infection and dehiscence of lotus petal flaps was seen postoperatively. Initial management consisted in antibiotics administration and removing necrotic tissue from surgical wound. After this initial treatment, negative wound pressure therapy was applied for 37 days with good results.

Discussion

Wound dehiscence in radical vulvectomy remains the most frequent complication in the treatment of vulvar cancer. The treatment of this complications is still challenging for most gynecologic oncologist surgeons.

Conclusion

The utilization of the negative wound pressure therapy could contribute to reduce hospitalization and the direct and indirect costs of these complications.

Treatment and follow-up in an asymptomatic malignant struma ovarii: A case report

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Struma ovarii is a rare and asymptomatic ovarian tumor and is usually diagnosed by the pathologist.

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Struma ovarii malignancy is from thyroid origin and usually associated with thyroid tumors.

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Management and follow up is not well established.

Introduction

Struma ovarii is a rare ovarian tumor, representing 0.5-1% of all ovarian tumors and 2–5% of ovarian teratomas. It is defined as an ovarian teratoma composed mostly of thyroid tissue. The symptoms are nonspecific, and the imaging studies can help in characterize the mass; however, the definitive diagnosis is usually given by the Pathologist. Classically, the treatment is the surgical resection of the ovarian mass, however there is no consensus regarding the follow-up.

Presentation of case

An asymptomatic malignant struma ovarii in a 43 year-old patient is presented. The diagnosis was postoperatively following a laparoscopic adnexectomy due to an apparently benign ovarian teratoma. The histopathology results revealed a mature ovarian cystic teratoma with papillary carcinoma with immunohistochemical characteristics suggesting a thyroid origin. Seeing that there was no thyroid affectation or metastatic disease, we decided a conservative management. A yearly follow-up with CT scan and tumor markers was performed. The endocrinologist also performed annual controls with thyroid ultrasound and serum tests. The patient has remained asymptomatic during these last four years.

Discussion

There is little evidence in literature on the conservative management in cases with evidence of malignancy. If fertility preservation is desired, an unilateral oophorectomy could be performed, along with levels of serum thyroglobulin as a marker of relapse. Other authors claim for aggressive ovarian cancer surgery followed by a total thyroidectomy. There is still no established management for struma ovarii patients and the choice for a conservative or radical approach depends only on the professional decision.

EVALUATION RETREAT: A SENSIBLE METHOD FOR PROGRAM'S ASSESSMENT

PURPOSE

The University of Puerto Rico (UPR), Medical Sciences Campus (MSC) post-doctoral Master of Science in Clinical and Translational Research (MSc) program aims to train Hispanic post-doctoral candidates to advance their careers and become successful clinical and translational researchers geared to help eliminate health disparities. Its curriculum highlights the use of technology and online resources to maximize time use of time and efforts. As part of the assessment efforts, the program's Evaluation Committee leads an annual activity, Evaluation Retreat (ER), to evaluate the program's curriculum, research component, and mentoring experience according to Scholars' perspective. Results are used by the Program Executive committee for further planning and improvement. This analysis presents the most relevant results from these activities.

DESIGN METHODS

Data collection (from last 5 years), include quantitative (online surveys) and qualitative approaches (a group meeting with Scholars.) Questionnaires request Scholars to rate specific features of the program's research component, mentoring experience and curriculum. It also includes questions about the program in general (major strengths and challenges, and recommendations for improvement. During the group meeting, Scholars discuss these results and present consensus in a plenary session. Quantitative data are managed and analyzed using the statistical software SPSS. Qualitative data are examined using content analysis.

RESULTS

Scholars identified as program's strengths the networking opportunities (local and with U.S. experts), the diversity of peers and faculty, the faculty support, the technical and audiovisual support, the physical facilities and resources, the guest speakers and consultants, and the quality of the curriculum. Challenges vary as cohorts change, but time limitations and the need for technical/statistical support are always highlighted. Recommendations for improvement emphasize the need for a greater pool of experienced mentors, and more hands-on approaches to address particular skills such as, manuscript development, institutional and federal guidelines for proposal submission, and issues related to the research project management.

DISCUSSION

Evaluation Retreats provide a valuable input to improve a program geared to develop competent clinical researchers. Findings evidence the program's commitment with providing the foundation for an enhanced mass of clinical researchers.