A.N. Al-Niaimi

Preoperative hypoalbuminemia is an independent predictor of poor perioperative outcomes in women undergoing open surgery for gynecologic malignancies.

OBJECTIVE To quantify the impact of preoperative hypoalbuminemia on 30-day mortality and morbidity after gynecologic cancer surgery. METHODS Patients included in the National Surgical Quality Improvement Program (NSQIP) dataset who underwent any non-emergent surgery for gynecologic malignancy between 1/1/2008 and 12/31/2010 were identified. Analysis was conducted with albumin both as a dichotomous variable (<3.5 g/dl was defined as low albumin) and as a continuous variable to determine a clinically relevant cut-off value. RESULTS Of the total 3171 patients identified, 2110 had preoperative albumin levels available for analysis. In addition, 279 (13.3%) of these patients had low albumin levels. According to multivariate analysis, the low albumin group had significantly higher odds of developing one or more post-operative complications (OR-2,CI: 1.47-2.73, p<0.0001), three or more complications (OR-4.1,CI: 2.31-7.1, p<0.0001), surgical complications (OR-2.39,CI: 1.59-3.58, p<0.0001), thromboembolic complications (OR-2.59,CI: 1.33-5.06, p<0.0001), pulmonary complications (OR-4.06,CI: 2.05-8.03, p<0.0001), or infectious complications (OR-1.84,CI: 1.26-2.69, p<0.0001) and a higher 30-day mortality (OR-6.52,CI: 2.51-16.95, p<0.0001). Upon subgroup analysis, this difference was not found in patients undergoing laparoscopic surgery. In patients undergoing open surgery, the probability of experiencing one or more post-operative complications increased linearly with the decrease in albumin level; however, the probability of patients experiencing three or more complications and 30-day mortality increased sharply as soon as the albumin level decreased below 3g/dl. CONCLUSION Preoperative albumin levels <3g/dL identify a population of patients at a very high-risk of experiencing perioperative morbidity and 30-day mortality after open surgery.

Intensive postoperative glucose control reduces the surgical site infection rates in gynecologic oncology patients

OBJECTIVE SSI rates after gynecologic oncology surgery vary from 5% to 35%, but are up to 45% in patients with diabetes mellitus (DM). Strict postoperative glucose control by insulin infusion has been shown to lower morbidity, but not specifically SSI rates. Our project studied continuous postoperative insulin infusion for 24h for gynecologic oncology patients with DM and hyperglycemia with a target blood glucose of <139 mL/dL and a primary outcome of the protocols impact on SSI rates. METHODS We compared SSI rates retrospectively among three groups. Group 1 was composed of patients with DM whose blood glucose was controlled with intermittent subcutaneous insulin injections. Group 2 was composed of patients with DM and postoperative hyperglycemia whose blood glucose was controlled by insulin infusion. Group 3 was composed of patients with neither DM nor hyperglycemia. We controlled for all relevant factors associated with SSI. RESULTS We studied a total of 372 patients. Patients in Group 2 had an SSI rate of 26/135 (19%), similar to patients in Group 3 whose rate was 19/89 (21%). Both were significantly lower than the SSI rate (43/148, 29%) of patients in Group 1. This reduction of 35% is significant (p = 0.02). Multivariate analysis showed an odd ratio = 0.5 (0.28-0.91) in reducing SSI rates after instituting this protocol. CONCLUSIONS Initiating intensive glycemic control for 24h after gynecologic oncology surgery in patients with DM and postoperative hyperglycemia lowers the SSI rate by 35% (OR = 0.5) compared to patients receiving intermittent sliding scale insulin and to a rate equivalent to non-diabetics.

Transversus abdominis plane block in robotic gynecologic oncology: A randomized, placebo-controlled trial

OBJECTIVE Although robotic surgery decreases pain compared to laparotomy, postoperative pain can be a concern near the site of a larger assistant trocar site. The aim of this study was to determine the efficacy of transversus abdominis plane (TAP) block on 24-hour postoperative opiate use after robotic surgery for gynecologic cancer. METHODS Sixty-four subjects with gynecologic malignancies who were scheduled to undergo robotic surgery were enrolled into the study. They were randomized to receive a unilateral TAP block to the side of the assistant port via ultrasound guidance. The block was comprised of 30 cc of 0.25% bupivacaine with 3 mcg/mL epinephrine or saline. Opiate use was measured and converted into IV morphine equivalents. Patient-reported pain was measured using the Brief Pain Inventory (BPI) and Visual Analog Scale (VAS). RESULTS The treatment group used a mean of 64.9 mg morphine in the first 24h compared to 69.3mg for controls (primary outcome, p=0.52). After age-adjustment, the treatment group used a mean of 11.1mg morphine less than controls (p=0.09). Postoperative pain scores assessed by the BPI (6.44 vs. 6.97, p=0.37) and the VAS (3.12 vs. 3.61, p=0.30) were equivalent. Block placement was uncomplicated in 98.4% of participants with mean BMI of 35.3 kg/m(2). Linear regression revealed an approximate 8.1mg decrease in morphine equivalents used per additional decade of life (p=0.0008). There was a positive correlation between the amount of opiates and BMI with an additional 8.8 mg of morphine per 10 kg/m(2) increase in BMI (p=0.0012). CONCLUSIONS TAP block is safe and feasible in this patient population with a large proportion of morbid obesity. Preoperative TAP block does not significantly decrease opiate use. However; based on these data, a clinically useful nomogram has been created to aid clinicians in postoperative opiate-dosing for patients based on age and BMI.

Incidence and risk factors for surgical site infection post-hysterectomy in a tertiary care center

Background: Preoperative antibiotic prophylaxis and surgical technological advances have greatly reduced, but not totally eliminated surgical site infection (SSI) posthysterectomy. We aimed to identify risk factors for SSI posthysterectomy among women with a high prevalence of gynecologic malignancies, in a tertiary care setting where compliance with the Joint Commissions Surgical Care Improvement Project core measures is excellent. Methods: The study was a matched case–control, 2 controls per case, matched on date of surgery. Study time was January 2, 2012‐December 31, 2015. Procedures included abdominal and vaginal hysterectomies (open, laparoscopic, and robotic). SSI (superficial incisional or deep/organ/space) was defined as within 30 days postoperatively, per Centers for Disease Control and Prevention criteria. Statistical analysis included bivariate analysis and conditional logistic regression controlling for demographic and clinical variables, both patient‐related and surgery‐related, including detailed prophylactic antibiotic exposure. Results: Of the total 1,531 hysterectomies performed, we identified 52 SSIs (3%), with 60% being deep incisional or organ/space infections. All case patients received appropriate preoperative antibiotics (timing, choice, and weight‐based dosing). Bivariate analysis showed that higher median weight, higher median Charlson comorbidity index, immune suppressed state, American Society of Anesthesiologists score ≥ 3, prior surgery within 60 days, clindamycin/gentamicin prophylaxis, surgery involving the omentum or gastrointestinal tract, longer surgery duration, ≥4 surgeons present in the operating room, higher median blood loss, ≥7 catheters or invasive devices in the operating room, and higher median length of hospital stay increased SSI risk (P < .05 for all). Cefazolin preoperative prophylaxis, robot‐assisted surgery, and laparoscopic surgery were protective (P < .05 for all). Duration of surgery was the only independent risk factor for SSI identified on multivariate analysis (odds ratio, 3.45; 95% confidence interval, 1.21‐9.76; P = .02). Conclusions: In our population of women with multimorbidity and hysterectomies largely due to underlying gynecologic malignancies, duration of surgery, presumed a marker of surgical complexity, is a significant SSI risk factor. The choice of preoperative antibiotic did not alter SSI risk in our study.

Epithelial Ovarian Cancer

Epithelial ovarian cancer is the deadliest gynecologic malignancy, constituting the fourth most common cause of death in women and the fifth most common among United States women, after cancers of the lung, breast, colon, and uterus. More than 1,550 cases of ovarian cancer are diagnosed annually in the United States, with pproximately 14,500 dying from this disease. A woman’s overall lifetime risk for pithelial ovarian cancer is 1.7 % unless increased because of familial risk.

Safety and tolerability of chlorhexidine gluconate (2%) as a vaginal operative preparation in patients undergoing gynecologic surgery

BACKGROUND The use of chlorhexidine gluconate (CHG) as an intraoperative vaginal preparation has been shown to be more effective than vaginal povidone-iodine (PI) in decreasing vaginal bacterial colony counts. However, PI remains the standard vaginal preparation because of concerns of CHGs potential for vaginal irritation. The primary outcome of this study is a comparison of the rate of patient-reported vaginal irritation between 2% CHG and PI. METHODS Consecutive patients were enrolled in a pre-post study. Group 1 consisted of consecutive patients who received PI as a vaginal preparation. Group 2 consisted of consecutive patients who received 2% CHG as a vaginal preparation. Patients used a standardized instrument to report irritation to trained nurse practitioners 1 day after surgery. RESULTS A total of 117 patients received vaginal operative preparation during the course of the study, with 64 patients in group 1 and 53 patients in group 2. Of the patients in group 1, 60 (93.7%) reported no vaginal irritation, 3 (4.69%) reported mild irritation, and 1 (1.56%) reported moderate irritation. In group 2 (2% CHG vaginal preparation), all of the patients (100%) reported no vaginal irritation (P = .38). CONCLUSIONS The use of 2% CHG as a vaginal operative preparation is not associated with increased vaginal irritation compared with PI in gynecologic surgery. It can safely be used, taking advantage of its efficacy in reducing vaginal bacterial colony counts.

False positive PET–CT scan and clinical examination in a patient with locally advanced vulvar cancer

► PET-CT scan was positive for metastasis of vulvar cancer to lymph nodes however they were histologically negative. ► Frozen section analysis should be performed at the time of surgery to confirm status of suspicious lymph nodes.

The Feasibility and Safety of Adopting Single-Incision Laparoscopic Surgery into Gynecologic Oncology Practice

STUDY OBJECTIVE To determine the complications associated with single-incision laparoscopy in gynecologic oncology surgery. DESIGN A retrospective cohort (Canadian Task Force classification II-3). SETTING A single academic institution. PATIENTS One hundred fifteen consecutive patients undergoing single-incision laparoscopy with suspected gynecologic oncology conditions. INTERVENTIONS Single-incision laparoscopy. MEASUREMENTS AND MAIN RESULTS One hundred fifteen patients underwent single-incision laparoscopy. The mean age was 55.3 ± 13.1 years. For procedures completed via single-incision laparoscopy (102/115 [88.7%]), the mean operative time was 130.7 ± 55.5 minutes. The average blood loss was 63 ± 111 mL. The conversion to open rate was 13 of 115 (12.17%). The conversion rate of the 55 patients with benign conditions was lower (2/55 [3.64%]) compared with the 60 patients with malignant conditions (11/60 [18.33%]). The hernia rate was 2 of 115 (1.80%), 1 of which was a recurrent hernia. The median time for follow-up was 30 days (range, 5-653 days). CONCLUSION Single-incision laparoscopy provides a feasible, safe, and promising minimally invasive modality for treating gynecologic oncology patients.

Angiosarcoma originating from an ovarian mature teratoma, a rare disease with complex treatment modalities.

Highlights ► Ovarian angiosarcomas are rare and clinically aggressive neoplasms. ► In addition to surgery, taxol is the most studied adjuvant chemotherapy. ► Anti-angiogenic therapies can be considered as an option.

Thrombocytosis is Predictive of Postoperative Pulmonary Embolism in Patients With Gynecologic Cancer.

Objectives The prompt diagnosis of postoperative pulmonary embolism (PE) in gynecologic oncology patients is imperative, but the clinical presentation is nonspecific in this high-risk group. We sought to determine risk factors and clinical findings that may assist clinicians in diagnosing PE in the inpatient setting. Methods Radiology data were queried to identify patients with gynecologic cancer who had a postoperative PE evaluation with computed tomography pulmonary angiography (CT-PA). Patient clinical findings at the time of the PE evaluation were abstracted, and univariate and multivariate regression analyses were performed to identify predictors of PE. Results For 6 years, there were 2498 major gynecologic oncology surgical procedures performed at our institution. Within 14 days of surgery, 107 CT-PA studies were obtained with a positive study rate of 24.3%. In patients with and without PE, there was no significant difference noted for age, oxygen saturations, body mass index and heart rate. After controlling for stage, history of venous thromboembolism (VTE), heart rate, and oxygen saturation, platelet count (odds ratio, 1.26 per 50 counts increase; 95% confidence interval, 1.07–1.48; P = 0.006) and history of VTE (odds ratio, 17.1; 95% confidence interval, 1.77–Inf, P = 0.014) were identified as independent predictors of PE in the multivariate model. Conclusions Although clinicians often use tachycardia and low oxygen saturation as triggers to order PE imaging studies, these signs have a very low specificity. Given the findings of our study, accounting for high platelet count and history of VTE increases the pretest probability of CT-PA study.