Abstract Background Single port laparoscopy has gained popularity within minimally invasive gynecologic surgery for its feasibility, cosmetic outcomes and safety. However, within gynecologic ...oncology, there is limited data regarding short-term adverse outcomes and long term hernia risk in patients undergoing single port laparoscopic surgery. Objective To describe short-term outcomes and hernia rates in patients after single port laparoscopy in a gynecologic oncology practice. Methods A retrospective, single institution study was performed for patients who underwent single port laparoscopy from 2009-2015. Univariate analysis was performed with chi-square tests and t-tests; Kaplan Meier and Cox proportional hazards determined time to hernia development. Results 898 patients underwent 908 surgeries with a median follow-up of 37.2 months. The mean age and body mass index were 55.7 years and 29.6 kg/m2 , respectively. The majority were Caucasian (87.9%) and American Society of Anesthesiologists class II/III (95.5%). The majority of patients underwent surgery for adnexal masses (36.9%) and endometrial hyperplasia/cancer (37.3%). Most women underwent hysterectomy (62.7%) and removal of one or both fallopian tubes and/or ovaries (86%). Rate of adverse outcomes within 30 days, including reoperation (0.1%), intraoperative injury (1.4%), intensive care unit admission (0.4%), venous thromboembolism (0.3%) and blood transfusion, were low (0.8%). The rate of urinary tract infection was 2.8%; higher body mass index (p=0.02), longer operative time (p=0.02), smoking (p=0.01), hysterectomy (p=0.01), and cystoscopy (p=0.02) increased risk. The rate of incisional cellulitis was 3.5%. Increased estimated blood loss (p=0.03) and endometrial cancer (p=0.02) were independent predictors of incisional cellulitis. Rate for surgical readmissions was 3.4%; higher estimated blood loss (p=0.03), longer operative time (p=0.02), chemotherapy alone (p=0.03) and combined chemotherapy and radiation (p<0.05) increased risk. Rate of incisional hernia rate was 5.5% (n=50) with a mean occurrence at 570.2 ± 553.3 days. Higher American society of Anesthesiologists class (p=0.04), diabetes (p<0.001), hypertension (p=0.043), increasing age (p=0.017; HR 1.03) and body mass index (p<0.001; HR 1.08) were independent predictors for incisional hernia development. Previous abdominal surgeries (p=0.24) and hand-assist (p=0.64) were not associated with increased risk for incisional hernia. Patients with American society of Anesthesiologists class III/IV had a 3-year hernia rate of 12.8% (HR 1.81). Patients with diabetes mellitus had a 3-year hernia rate of 23.0% (HR 3.60). Conclusions In this large cohort of patients undergoing single port laparoscopy, the incidence of short-term adverse outcomes is low. While the rate of incisional hernia was 5.5%, incidence reached 23.0% at three years in high-risk groups. Previous studies with short follow up duration may underestimate the risk of hernia, especially in patients with significant comorbidities.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Minimally invasive hysterectomy is the standard of care in the majority of women diagnosed with endometrial cancer via robotic-assisted, multiport, and single-port laparoscopy technology. Although ...safe and efficacious, it is unclear how oncologic outcomes are impacted by surgical platform.
To identify differences in progression-free survival and overall survival in women undergoing minimally invasive surgery for endometrial cancer staging via either multiport, single-port, or robotic-assisted laparoscopy.
A multicenter, single-institution retrospective cohort study was performed in women with a diagnosis of endometrial cancer who underwent minimally invasive surgery from 2009 to 2015. Data were collected for demographics, pathologic information, adjuvant treatment, and disease status. Pearson χ2 and Fisher exact tests were used to evaluate risk factors for outcomes, Kaplan–Meier estimates and Cox proportional hazards were used to evaluate differences in time to progression or death, and multivariate regression analysis was performed.
In total, 1150 women with endometrial cancer underwent robotic-assisted laparoscopy (n=652), multiport laparoscopy (n=214), or single-port laparoscopy (n=284). The median age and body mass index of women was 62.0 years and 33.5 kg/m2, respectively. The majority of patients had endometrioid histology (88.1%), stage IA (74.7%) or IB disease (13.1%) and International Federation of Gynecology and Obstetrics grade 1 (57.4%) or 2 (26.0%) histology. Lymphovascular space invasion was present in 24.7% (n=283). Adjuvant radiation was given in 34.2% of cases, with 21.9% receiving vaginal brachytherapy, 6.6% pelvic radiation, and 5.4% both. For the entire cohort, there were no differences in progression-free survival at 2, 3, and 5 years for multiport laparoscopy (94.2%, 91.4%, 87.4%), robotic-assisted laparoscopy (94.5%, 92.9%, 88.8%), and single-port laparoscopy (93.6%, 91.2%, 90.0%) (P=.93), respectively. Similarly, there were no differences in overall survival at 2, 3, and 5 years for multiport laparoscopy (94.4%, 91.8%, 91.8%), robotic-assisted laparoscopy (95.6%, 93.4%, 90.7%), and single-port laparoscopy (95.0, 93.1, 91.8) (P=.99), respectively. Among women with stage IA and IB disease, no difference existed for progression-free survival at 2, 3, and 5 years for multiport laparoscopy (94.2%, 91.4%, 87.4%), robotic-assisted laparoscopy (94.5%, 92.9%, 88.8%), and single-port laparoscopy (93.6, 91.2, 90.0) (P=.93), respectively. Similarly, among women with stage I disease, there was no difference in overall survival at 2, 3, and 5 years for multiport laparoscopy (96.2%, 95.0%, 95.0%), robotic-assisted laparoscopy (96.6%, 95.4%, 93.3%), and single-port laparoscopy (96.6%, 95.0%, 93.4%) (P=.89). Rather, progression-free survival and overall survival were predicted by age >65 years, stage, grade, and histology (P<.05). On multivariate analysis, modality of surgery did not impact overall survival or progression-free survival (robotic-assisted laparoscopy, hazard ratio, 1.28, P=.50; single-port laparoscopy, hazard ratio, 0.84, P=.68 vs multiport laparoscopy). Age >65 years (hazard ratio, 5.42, P<.001) and advanced stage disease (P=.003) were associated with decreased overall survival.
In this retrospective cohort, there was no difference in progression-free survival or overall survival in women undergoing surgery for endometrial cancer via robotic-assisted laparoscopy, single-port laparoscopy, or multiport laparoscopy.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
To examine the effect of body mass index (BMI) on postoperative 30-day morbidity and mortality after surgery to treat endometrial cancer.
Retrospective cohort study (Canadian Task Force ...classification II-2).
National Surgical Quality Improvement Program.
Patients with endometrial cancer who underwent surgery from 2005 to 2011.
Women were grouped according to weight, as follows: normal weight (BMI 18 to <30), obese (BMI 30 to <40), and morbidly obese (BMI ≥ 40). Univariate and multivariable logistic regression models were analyzed.
Of 3947 patients, 38% were of normal weight, 38% were obese, and 24% were morbidly obese. Of these, 48% underwent laparoscopy and 52% underwent laparotomy. Overall 30-day morbidity and mortality were 13% and 0.7%, respectively. Obesity and morbid obesity were associated with a higher American Society of Anesthesiologists class, diabetes, and hypertension. Preoperatively, elevated serum creatinine concentration, hypoalbuminemia, and leukocytosis were more common in morbidly obese women than those of normal weight. Laparoscopic surgery was performed less frequently in morbidly obese women than in those of normal weight (42.5% vs 50%; p = .001). Morbidly obese patients were more likely to develop postoperative complications (morbidly obese 16% vs normal weight 13% vs obese 11%; p = .001), in particular surgical (morbidly obese 14% vs normal weight 11% vs obese 9%; p < .001) and infectious complications (morbidly obese 10% vs normal weight 5% vs obese 5%; p = .01). After laparotomy, morbidly obese women demonstrated a higher rate of any complication (normal weight 21%, obese 18%, morbidly obese 25%; p = .002), surgical complications (normal weight 18%, obese 14%, morbidly obese 22%; p = .002) and infectious complications (normal weight 6%, obese 10%, morbidly obese 16%; p < .001). After laparoscopy there was no difference in complication rates according to BMI group. The 30-day mortality was not significantly different according to BMI. After adjusting for confounders, obesity and morbid obesity did not independently predict 30-day morbidity or mortality.
Morbidly obese patients with endometrial cancer have more preoperative morbidities and postoperative complications, in particular surgical and infectious complications, and are less likely to undergo minimally invasive surgery. However, obesity was not an independent predictor of perioperative outcomes after controlling for other confounders.
Abstract Objective To assess whether chewing gum prevents postoperative ileus after laparotomy for benign gynecologic surgery. Methods A randomized study was conducted from December 1, 2010, to ...February 29, 2012. Patients scheduled to undergo laparotomy were randomly assigned to receive chewing gum or routine care after surgery. A chart review was performed to establish incidence of nausea and vomiting, use of antiemetics, cases of postoperative ileus (≥ 2 episodes of emesis of 100 mL or more, with abdominal distention and absence of bowel sounds), and time to discharge. Inpatient surveys recorded the time to specific events. Results A total of 109 patients were randomly assigned to receive chewing gum (n = 51) or routine postoperative care (n = 58). Fewer participants assigned to receive chewing gum than routine care experienced postoperative nausea (16 31.4% versus 29 50.0%; P = 0.049) and postoperative ileus (0 vs 5 8.6%; P = 0.032). There were no differences in the need for postoperative antiemetics, episodes of postoperative vomiting, readmissions, repeat surgeries, time to first hunger, time to toleration of clear liquids, time to regular diet, time to first flatus, or time to discharge. Conclusion Chewing gum after laparotomy for gynecologic surgery is safe and lowers the incidence of postoperative ileus and nausea. ClinicalTrials.gov: NCT01579175
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Objective The purpose of this study was to describe the acceptability of bariatric referrals when offered by gynecologic oncologists to women with a history of complex atypical hyperplasia or ...early-stage endometrial cancer and to detail compliance with referrals and weight loss attempts that are initiated 3 months after the referral. Study Design Obese women with complex atypical hyperplasia or early-stage endometrial cancer were approached for inclusion in this prospective cohort study. Those women who were not in the care of a bariatric specialist were offered a medical referral with or without a surgical referral. A survey was administered at inclusion and after 3 months. Results Of 121 women who were approached, 106 women were consented. Women reported that it was acceptable for their gynecologic oncologist to discuss weight loss (91.09%) and that a 10% loss of body weight would be beneficial (86.14%). Six women were already in the care of a bariatric specialist. Of the remaining 100 women, 43 accepted a referral: 35 of 100 medical and 8 of 66 surgical referrals that were offered. At 3 months, 17 women complied with a referral (16 medical and 1 surgical), and 59 women had initiated any weight loss attempt. On multivariate analysis, a higher initial weight ( P = .0403), Charlson Comorbidity Index ≥5 ( P = .0278), and shorter time from surgery to bariatric referral ( P = .0338) predicted acceptance of a referral. Conclusion Weight-loss counseling is well received by these women. After being offered bariatric referral, only 17% comply, but most women (59%) subsequently initiate a weight loss attempt. Referrals should be offered early in the course of cancer care to maximize acceptance.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
To estimate the frequency of hereditary breast and ovarian cancer (HBOC) in women with central nervous system (CNS) metastasis from epithelial ovarian cancer (EOC) and to evaluate for a potential ...relationship between HBOC status and survival.
A total of 1240 cases of EOC treated between 1995 and 2014 were reviewed to identify CNS metastasis. Demographics, treatment, family history, genetic testing, and survival outcomes were recorded. Women were then classified as HBOC+ or HBOC- based on histories and genetic testing results. Kaplan-Meier survival curves and univariable Cox proportional hazards models were used.
Of 1240 cases, 32 cases of EOC with CNS metastasis were identified (2.58%). Median age was 52.13 (95% confidence interval CI, 40.56-78.38) years, and 87.10% had stage III to IV disease. Among those with documented personal and family history, 66.7% (20/30) were suspicious for HBOC syndrome. Among those who underwent germline testing, 71.43% (5/7) had a pathogenic BRCA mutation. The median time from diagnosis to CNS metastasis was 29.17 (95% CI, 0-187.91) months. At a median survival of 5.97 (95% CI, 0.20-116.95) months from the time of CNS metastasis and 43.76 (95% CI, 1.54-188.44) months from the time of EOC diagnosis, 29 women died of disease. Univariate Cox proportional hazard models were used to compare HBOC- to HBOC+ women and did not reveal a significant difference for survival outcomes.
Confirmed BRCA mutations and histories concerning for HBOC syndrome are common in women with EOC metastatic to the CNS. We did not demonstrate a relationship between HBOC status and survival outcomes, but were not powered to do so.
The obesity pandemic continues to contribute to a worsening burden of disease worldwide. The link between obesity and diseases such as diabetes, cardiovascular disease, and cancer has been well ...established, yet most patients living with obesity remain untreated or undertreated. Metabolic and bariatric surgery is the most effective and durable treatment for obesity, is safe, and may have a protective benefit with respect to cancer incidence. In this review, an overview of the link between obesity, metabolic surgery, and cancer is discussed with emphasis on indications for endometrial cancer, the malignancy most strongly associated with obesity. Considerable evidence from retrospective and prospective cohort studies supports a decreased risk of endometrial cancer in patients with obesity who undergo bariatric surgery compared with nonsurgical controls. Survivors of endometrial cancer are at increased risk of poor health outcomes associated with obesity, and women with endometrial cancer are more likely to die of cardiovascular disease and other obesity-related illnesses than of the malignancy itself. Recent advances in anticancer drug therapies have targeted pathways that may also be therapeutically altered with metabolic surgery. Metabolic surgery has significant potential to enter the treatment paradigm for endometrial cancer, and gynecologic oncologist visits present an opportunity to identify patients who may benefit the most.
To report surgical and pathologic outcomes after single-port laparoscopy (SPL) for adnexal masses in patients referred to a gynecologic oncology practice at a single academic institution.
A ...retrospective analysis (Canadian Task Force Classification II.2).
A single academic institution with multiple hospital centers.
Women who underwent at least 1 single-port laparoscopic surgery for the treatment of an adnexal mass from 2009 to 2015 after referral to a gynecologic oncology practice.
Data were collected on the surgical procedure, patient demographic variables, 30-day surgical outcomes, and hernia development.
Three hundred twenty-five surgeries were performed in 322 patients with a median follow-up of 42.7 months. The median age was 54.5 years, and the median body mass index was 28.1 kg/m
. All patients underwent unilateral or bilateral salpingectomy or oophorectomy with or without hysterectomy (26.5%). The median operative time was 90.0 minutes. The median mass dimension was 6.4 cm with 17.9% (n = 60) greater than 10 cm. Masses were categorized as simple (11.4%) and complex (69.5%). Although the majority (87.4%) of masses were benign, 7.4% were malignant, and 5.2% were borderline. Benign masses were physiologic (16.6%), serous cystadenomas (19.1%), mucinous cystadenomas (6.8%), endometriomas (12.3%), myomas (12.3%), and mature teratomas (9.2%). In malignant cases (7.4%), serous carcinoma was the most frequent histology (58.3%). The rate of adverse outcomes within 30 days, including reoperation (0.0%), intraoperative injury (1.5%), venous thromboembolism (0.3%), and transfusion (0.6%), was low. The development of incisional cellulitis was 4.6%. The rate of incisional hernia was 4.0%, with a median occurrence of 18.3 months. Diabetes mellitus (p = .03) and obesity (p = .04) were significant predictors for a hernia, but mass complexity (p = .28), American Society of Anesthesiologists class (p = .83), and smoking (p = .82) were not.
In patients undergoing SPL for the removal of adnexal masses in a gynecologic oncology practice, the rate of benign disease is high. SPL removal of adnexal masses is feasible and safe with favorable surgical outcomes, rare short-term adverse outcomes, and a low incisional hernia rate.
Objective Obesity is associated with the development and risk of death from several women's cancers. The study objective was to describe and compare oncologic providers' attitudes and practices as ...they relate to obesity counseling and management in cancer survivors. Study Design Society of Gynecologic Oncology members (n = 924) were surveyed with the use of a web-based, electronic questionnaire. χ2 and Fisher exact tests were used to analyze responses. Results Of the 240 respondents (30%), 92.9% were practicing gynecologic oncologists or fellows, and 5.1% were allied health professionals. Median age was 42 years; 50.8% of the respondents were female. Of the respondents, 42.7% reported that they themselves were overweight/obese and that ≥50% of their survivor patients were overweight/obese. Additionaly, 82% of the respondents believed that discussing weight would not harm the doctor-patient relationship. Most of the respondents (95%) agreed that addressing lifestyle modifications with survivors is important. Respondents believed that gynecologic oncologists (85.1%) and primary care providers (84.5%) were responsible for addressing obesity. More providers who were ≤42 years old reported undergoing obesity management training ( P < .001) and were more likely to believe that survivors would benefit from obesity education than providers who were >42 years old ( P = .017). After initial counseling, 81.5% of the respondents referred survivors to other providers for obesity interventions. Conclusion Oncology provider respondents believe that addressing obesity with cancer survivors is important. Providers believed themselves to be responsible for initial counseling but believed that obesity interventions should be directed by other specialists. Further research is needed to identify barriers to care for obese cancer survivors and to improve physician engagement with obesity counseling in the “teachable moment” that is provided by a new cancer diagnosis.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Breast and gynecological cancers affect almost 900,000 women and therefore most health care providers will be involved at some point in the management of women with cancer. As the prognosis of all ...cancers is much more favorable when diagnosed in early stages, it is imperative that all health care providers are familiar not only with current screening guidelines for the average population, but also with the identification of high risk individuals who may benefit from more intense screening as well as available interventions to prevent disease or decrease risk. The purpose of this review article is to provide relevant information to physicians and other health care providers to aid in identifying patients that are classified as "high risk" for developing breast or a gynecologic cancer, outlining what interventions exist for adequate screening and risk reduction strategies, and to provide an update on current screening guidelines for individuals at average and high risk.
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