Mark Lachiewicz

Pelvic Surgical Site Infections in Gynecologic Surgery

The development of surgical site infection (SSI) remains the most common complication of gynecologic surgical procedures and results in significant patient morbidity. Gynecologic procedures pose a unique challenge in that potential pathogenic microorganisms from the skin or vagina and endocervix may migrate to operative sites and can result in vaginal cuff cellulitis, pelvic cellulitis, and pelvic abscesses. Multiple host and surgical risk factors have been identified as risks that increase infectious sequelae after pelvic surgery. This paper will review these risk factors as many are modifiable and care should be taken to address such factors in order to decrease the chance of infection. We will also review the definitions, microbiology, pathogenesis, diagnosis, and management of pelvic SSIs after gynecologic surgery.

Prevalence of occult gynecologic malignancy at the time of risk reducing and nonprophylactic surgery in patients with Lynch syndrome

OBJECTIVE The primary aim of this study was to determine the prevalence of occult gynecologic malignancy at the time of risk reducing surgery in patients with Lynch Syndrome. A secondary aim was to determine the prevalence of occult gynecologic malignancy at the time of surgery for non-prophylactic indications in patients with Lynch Syndrome. METHODS A retrospective review of an Inherited Colorectal Cancer Registry found 76 patients with Lynch syndrome (defined by a germline mutation in a DNA mismatch repair gene) or hereditary nonpolyposis colorectal cancer (HNPCC) (defined by Amsterdam criteria) who had undergone hysterectomy and/or salpingo-oophorectomy for a prophylactic or non-prophylactic indication. Indications for surgery and the prevalence of cancer at the time of each operation were reviewed. RESULTS 24 of 76 patients underwent prophylactic hysterectomy and/or bilateral salpingo-oophorectomy for Lynch syndrome or HNPCC. In 9 of these patients, a benign indication for surgery was also noted. 4 of 24 patients (17%, 95% CI = 5-38%) were noted to have cancer on final pathology. 20 of 76 patients (26%) undergoing operative management for any indication were noted to have occult malignancy on final pathology. CONCLUSIONS Patients should be counseled about the risks of finding gynecologic cancer at the time of prophylactic or non-prophylactic surgery for Lynch syndrome and HNPCC, and the potential need for additional surgery.

Margins for cervical and vulvar cancer

Surgery is the primary treatment for vulvar cancer as well as early‐stage carcinoma of the cervix. This article reviews the significance of margin status after surgery on overall survival, need for further surgical intervention, and role for possible adjuvant therapy. It summarizes the abundant literature on margin status in vulvar cancer and highlights the need for further investigation on the prognostic significance of margins in cervical cancer. In addition, it reviews other important operative considerations. J. Surg. Oncol. 2016;113:304–309.

Risk factors for robotic gynecologic procedures requiring conversion to other surgical procedures.

To determine the incidence of, and risk factors for, conversion from robotic gynecologic procedures to other procedure types.

Endomyometritis after cesarean delivery in the era of antibiotic prophylaxis: incidence and risk factors

Abstract Purpose: To identify the rate of postpartum endomyometritis (PPE) after cesarean delivery (CD) in the era of antibiotic prophylaxis and determine risk factors. Methods: A single institution retrospective study was performed in women undergoing CD. Data regarding obstetrical and surgical variables were collected. Diagnosis of PPE was made clinically. Results: Among 2419 patients, the rate of PPE was 1.6% (n = 38) and was associated with lower age (27.0 versus 31.0; p < .001). 65.7% of patients having chorioamnionitits developed PPE, but only 5.4% of patients without PPE had chorioamnionitis (p < .001). On multivariate analysis, PPE was higher in emergent versus scheduled CD (OR: 5.89; p = .0081). There was no difference in PPE for cefazolin 2 g versus 1 g (OR: 1.91; p = .17) or 3 g versus 1 g (OR: 3.69; p = .29), gentamicin/clindamycin versus cefazolin (OR: 5.60; p < .001) had higher PPE. Women with PPE were more likely to have labor arrest (OR: 4.336; p = .001), sexually transmitted infection during the pregnancy (OR: 4.197; p = .02) or blood transfusion (OR: 9.50; p < .0001). Conclusions: While the overall rate of PPE was low, several risk factors were identified. Preoperative diagnosis of chorioamnionitits is associated with a higher rate of PPE. Further studies are needed to identify optimal regimens for antimicrobial prophylaxis in women undergoing CD.

Surgical site infection after cesarean delivery: incidence and risk factors at a US academic institution

Abstract Purpose: To identify the rate of surgical site infection (SSI) after Cesarean delivery (CD) and determine risk factors predictive for infection at a large academic institution. Methods: This was a retrospective cohort study in women undergoing CD during 2013. SSIs were defined by Centers for Disease Control (CDC) criteria. Chi square and t-tests were used for bivariate analysis and multivariate logistic regression was used to identify SSI risk factors. Results: In 2419 patients, the rate of SSI was 5.5% (n = 133) with cellulitis in 4.9% (n = 118), deep incisional infection in 0.6% (n = 15) and intra-abdominal infection in 0.3% (n = 7). On multivariate analysis, SSI was higher among CD for labor arrest (OR 2.4; 95%CI 1.6–3.5; p <.001). Preterm labor (OR 2.8; 95%CI 1.3–6.0; p = .01) and general anesthesia (OR 4.4; 95%CI 2.0–9.8; p = .003) were predictive for SSI. Increasing BMI (OR 1.1; 95%CI 1.05–1.09; p = .02), asthma (OR 1.9; 95%CI 1.1–3.2; p = .02) and smoking (OR 1.9; 95%CI 1.1–3.2; p = .02) were associated with increased SSI. Conclusions: Several patient and surgical variables are associated with increased rate of SSI after CD. Identification of risk factors for SSI after CD is important for targeted implementation of quality improvement measures and infection control interventions.

Catheter-associated urinary tract infection (CAUTI) after term cesarean delivery: incidence and risk factors at a multi-center academic institution.

Abstract Purpose: The purpose of this study is to identify the rate of catheter-associated urinary tract infection (CAUTI) after Cesarean delivery (CD) and to determine if any factors increase risk of infection. Methods: A retrospective cohort study was performed at a multi-center institution for patients who underwent CD in 2013. All patients had urinary catheters inserted before surgery. Diagnosis followed IDSA guidelines with culture growing greater than 103 CFU of bacteria per mL with symptoms or symptomatic urinary tract infections treated at provider discretion. Statistical analysis was assessed with Chi-square and Student’s t-test followed by logistic regression. Results: Of 2419 patients, 36 patients developed CAUTI (1.5%). In the 24 (66.7%) cases diagnosed by IDSA guidelines, Escherichia coli was the most common causative organism (54.1%); followed by Enterococcus faecalis (16.7%), Streptococccus agalactiae (8.3%), and Group A Streptococcus (8.3%). Longer operative time (OR 1.013; 95% 1.002–1.023; p = .02) and pregnancies complicated by STI (OR 4.15; 95% CI 1.11–15.0; p < .05) were associated with higher rates of CAUTI. Conclusions: The overall rate of CAUTI after CD was low at 1.5%. Escherichia coli was the most common causative pathogen. Identification of the patients at high risk for CAUTI allows for risk reduction measures.

A model to predict risk of postpartum infection after Caesarean delivery

Abstract Purpose: The purpose of this study is to build and validate a statistical model to predict infection after caesarean delivery (CD). Methods: Patient and surgical variables within 30 d of CD were collected on 2419 women. Postpartum infection included surgical site infection, urinary tract infection, endomyometritis and pneumonia. The data were split into model development and internal validation (1 January–31 August; N = 1641) and temporal validation subsets (1 September–31 December; N = 778). Logistic regression models were fit to the data with concordance index and calibration curves used to assess accuracy. Internal validation was performed with bootstrapping correcting for bias. Results: Postoperative infection occurred in 8% (95% CI 7.3–9.9), with 5% meeting CDC criteria for surgical site infections (SSI) (95% CI 4.1–5.8). Eight variables were predictive for infection: increasing BMI, higher number of prior Caesarean deliveries, emergent Caesarean delivery, Caesarean for failure to progress, skin closure using stainless steel staples, chorioamnionitis, maternal asthma and lower gestational age. The model discriminated between women with and without infection on internal validation (concordance index = 0.71 95% CI 0.67–0.76) and temporal validation (concordance index = 0.70, 95% CI 0.62, 0.78). Conclusions: Our model accurately predicts risk of infection after CD. Identification of patients at risk for postoperative infection allows for individualized patient care and counseling.

What Should a Gynecologist Know about Li-Fraumeni Syndrome? Lessons from a Patient Undergoing Hysterectomy for Benign Indications

Li-Fraumeni syndrome (LFS) is a rare highly penetrant cancer syndrome characterized by mutation in the TP53 tumor suppressor gene. Recent data suggest that this germline mutation is more frequent than once thought. While LFS has not been associated previously with pelvic serous carcinoma, gynecologic malignancies have been reported in this patient population. We present the case report of a 37-year-old patient with known LFS and a history of multiple cancers who underwent total abdominal hysterectomy for benign indications with incidental bilateral salpingo-oophorectomy. On final pathology, she was found to have serous tubal intraepithelial carcinoma of bilateral fallopian tubes. Our findings raise the question of the potential role of prophylactic gynecologic cancer-reducing surgery in this patient population.

Ovarian carcinoma initially presenting as breast cancer two years prior to diagnosis: A case report and review of literature

Highlights • Ovarian cancer presenting as a primary breast cancer two years prior• Ovarian cancer with metastases to breast is rare.• Metastases to the breast generally present as a recurrence.• Delay in diagnosis likely due to chemotherapy given for breast disease