Martin A. Martino

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 &khgr;2 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

A cost analysis of postoperative management in endometrial cancer patients treated by robotics versus laparoscopic approach

OBJECTIVE The purpose of this study is to compare postoperative pain management and costs in endometrial cancer patients who had a robotic-assisted or laparoscopic-assisted hysterectomy. METHODS This is a retrospective cohort study of all endometrial cancer patients from 9/2005 to 6/2010 who had a completed robotic-assisted or laparoscopic-assisted hysterectomy. All surgeries were performed by gynecologic oncologists on the da Vinci S surgical system. Demographic data, patient-recorded pain scores, pain-management interventions, and postoperative pain medication costs were compared. Data was analyzed using Students t-tests and Pearsons χ(2) tests in SPSS. RESULTS Two-hundred fifteen (101 robotic and 114 laparoscopic) patients met the inclusion criteria. There were no significant differences between the groups in age, BMI, clinical stage, comorbidities, lymph nodes retrieved, and the number of narcotic vs. non-narcotic drug interventions administered. Robotic patients had a lower number of initial drug interventions (21 vs. 52; P<.001) and total drug interventions (162 vs. 219; P<.001) than laparoscopic patients. Robotics had a lower initial pain score (2.1 vs. 3.0; P=.012). There was a 50% reduction in the pain medication cost on the day of surgery for robotic patients (

Incorporating resident/fellow training into a robotic surgery program

12.24 vs.

Preoperative enoxaparin is safe to use in major gynecologic surgery for prophylaxis of venous thromboembolism: a retrospective cohort study.

24.45; P<.01), and a 56% cost reduction for the rest of their length of stay (

Robotic Surgery in Gynecologic Oncology: Updates and Innovations

3.63 vs.

Upper vaginectomy for the treatment of vaginal intraepithelial neoplasia

8.17; P<.01). CONCLUSION Endometrial cancer patients who have robotic surgery experience less initial postoperative pain and have fewer drug interventions. The cost associated for their pain management represents a savings of greater than 50%. These factors demonstrate the value of robotic surgery in regard to postoperative pain management by delivering higher quality care at a lower cost.

Expression Analysis of Genes Involved in Ovarian Cancer Metastasis.

With the rapid uptake of the robotic approach in gynecologic surgery, a thorough understanding of the technology, including its uses and limitations, is critical to maximize patient outcomes and safety. This review discusses the role of training modalities and development of curricula for robotic surgery. Furthermore, methods for incorporating the entire surgical team and the process of credentialing/maintaining privileges are described. J. Surg. Oncol. 2015;112:684–689.

Lysophospholipids Are Potential Biomarkers of Ovarian Cancer

Objective To evaluate the safety of preoperative enoxaparin in patients undergoing major gynecologic oncology surgery. Methods We identified a retrospective cohort group of patients undergoing major gynecologic oncology surgery from June 2002 to June 2004. Exclusion criteria included laparoscopic surgery, inferior vena cava filter, history of venous thromboembolism, and current anticoagulation for prior venous thromboembolism. All patients received prophylaxis with sequential pneumatic compression devices and early ambulation. We identified patients who received (preoperative and postoperative) enoxaparin (20–40 mg) and compared them to patients who received no additional prophylaxis other than pneumatic compression alone. Patient outcomes including estimated blood loss, blood transfusions, operative time, and length of hospital stay were collected. Statistical analysis was performed using the &khgr;2 Wilcoxon rank sum tests. This study was approved by the institutional review board. Results We identified 122 patients who met our study criteria; there were 63 patients who received preoperative enoxaparin and 59 patients who received no additional prophylaxis. Both groups were similar in age, body mass index, race, comorbidities, cancer diagnosis, and surgical procedure. There was no significant difference between the enoxaparin group and the sequential pneumatic compression devices–only group regarding transfusion rates (29% and 27%; P = 0.86), operating time (150 and 140 minutes; P = 0.16), blood loss greater than 500 cc (35% and 37%; P = 0.79), and length of stay (5 vs 6 days). Conclusion The use of preoperative enoxaparin is not associated with increased blood loss, transfusion requirements, operative time, or hospital stay among patients having major gynecologic surgery.

Identification of genes associated with ovarian cancer metastasis using microarray expression analysis

Surgical advances in minimally invasive surgery, including laparoscopic and robotics, have revolutionized the practice of medicine and surgery in gynecologic oncology. During this time, an emphasis has been made to improve quality metrics such as complications, readmissions, and length of stay. The Institute for Healthcare Improvement has recommended health systems and surgeons to improve performance focused on better care, better quality, and better cost. Minimally invasive surgery may help to achieve these measures and serve as the foundation upon which these goals are reached. Despite the availability of laparoscopic tools at many hospitals, the majority of patients who had gynecologic cancer surgery in the United States had a laparotomy prior to the introduction of robot-assisted surgery. Reasons for this have been attributed to limitations of laparoscopy, which include 2D vision and rigid instruments without articulation. One of the greatest advancements in gynecologic surgery occurred in 2005, when the FDA approved the da Vinci surgical platform (Intuitive Surgical Inc, Sunnyvale, CA, USA) for use in gynecologic surgery. This platform provides a 3D vision system paired with wristed articulating instruments. Together, these enhancements may overcome some of the limitations of laparoscopy allowing for surgeons to perform less open surgery. The introduction of robotics in 2005 has led to an increase in minimally invasive surgery and significantly less open surgery – especially for the gynecologic oncology patient. This review will focus on recent advancements in robotic surgery in the field of gynecology oncology. It will also discuss the role for standardizing education and training through the development of training and educational networks to improve surgical outcomes.

Cytoreductive surgery for patients with recurrent epithelial ovarian carcinoma.

OBJECTIVE The purpose of this study was to evaluate the use of upper vaginectomy for the treatment of vaginal intraepithelial neoplasia (VAIN). STUDY DESIGN We conducted a retrospective review. Between August 1, 1985 and April 30, 2004, 105 patients were identified who had undergone upper vaginectomy for VAIN. RESULTS Thirty-six patients had previously been treated for VAIN. Mean operative time and estimated blood loss were 55 minutes and 113 mL, respectively. Ten percent had intraoperative complications. Twenty-three (22%) patients had negative findings on final pathologic examination, and invasive cancer was found in 13 (12%) patients. Four patients had postoperative complications. Follow-up was available in 52 patients; 46 (88%) remain without recurrence at a mean follow-up of 25 months. CONCLUSION In our patients, upper vaginectomy was efficacious for the treatment of VAIN. The procedure led to the diagnosis of occult invasive cancer in 12% of these women.