Gynecologic Cancer Surgery Research Articles

Compliance with preoperative glucose testing and USPSTF diabetes screening guidelines in gynecologic oncology patients on an enhanced recovery pathway (408)

Compliance with preoperative glucose testing and USPSTF diabetes screening guidelines in gynecologic oncology patients on an enhanced recovery pathway (408)

Association between high preoperative body mass index and mortality after cancer surgery.

Despite an association between obesity and increased mortality in the general population, obesity has been paradoxically reported with improved mortality of surgery and some types of cancer. However, this has not been fully investigated in patients undergoing cancer surgery. Using a cohort consisting of mostly Asian population, we enrolled 87,567 adult patients who underwent cancer surgery from March 2010 to December 2019. They were divided into three groups according to body mass index (BMI): 53,980 (61.6%) in the normal (18.5–25 kg/m2), 2,787 (3.2%) in the low BMI (<18.5 kg/m2), and 30,800 (35.2%) in the high BMI (≥25 kg/m2) groups. The high BMI group was further stratified into overweight (25–30 kg/m2) and obese (≥30 kg/m2) groups. The primary outcome was mortality during three years after surgery. Following adjustment by inverse probability weighting, mortality during three years after surgery was significantly lower in the high BMI group than the normal (4.8% vs. 7.0%; hazard ratio [HR], 0.69; confidence interval [CI], 0.64–0.77; p < 0.001) and low BMI (4.8% vs. 13.0%; HR: 0.38; CI: 0.35–0.42; p < 0.001) groups. The mortalities of the overweight and obese groups were lower than that of the normal group (7.0% vs. 5.0%; HR: 0.72; CI: 0.67–0.77; p < 0.001 and 7.0% vs. 3.3%; HR: 0.57; CI: 0.50–0.65; p < 0.001, respectively). This association was not observed in female patients and those undergoing surgery for breast and gynecological cancers. High BMI may be associated with decreased mortality after cancer surgery. Further investigations are needed for clinical application of our finding.

Outcomes of gynecologic cancer surgery during the COVID-19 pandemic: an international, multicenter, prospective CovidSurg-Gynecologic Oncology Cancer study

BackgroundThe CovidSurg-Cancer Consortium aimed to explore the impact of COVID-19 in surgical patients and services for solid cancers at the start of the pandemic. The CovidSurg-Gynecologic Oncology Cancer subgroup was particularly concerned about the magnitude of adverse outcomes caused by the disrupted surgical gynecologic cancer care during the COVID-19 pandemic, which are currently unclear.ObjectiveThis study aimed to evaluate the changes in care and short-term outcomes of surgical patients with gynecologic cancers during the COVID-19 pandemic. We hypothesized that the COVID-19 pandemic had led to a delay in surgical cancer care, especially in patients who required more extensive surgery, and such delay had an impact on cancer outcomes.Study DesignThis was a multicenter, international, prospective cohort study. Consecutive patients with gynecologic cancers who were initially planned for nonpalliative surgery, were recruited from the date of first COVID-19-related admission in each participating center for 3 months. The follow-up period was 3 months from the time of the multidisciplinary tumor board decision to operate. The primary outcome of this analysis is the incidence of pandemic-related changes in care. The secondary outcomes included 30-day perioperative mortality and morbidity and a composite outcome of unresectable disease or disease progression, emergency surgery, and death.ResultsWe included 3973 patients (3784 operated and 189 nonoperated) from 227 centers in 52 countries and 7 world regions who were initially planned to have cancer surgery. In 20.7% (823/3973) of the patients, the standard of care was adjusted. A significant delay (>8 weeks) was observed in 11.2% (424/3784) of patients, particularly in those with ovarian cancer (213/1355; 15.7%; P<.0001). This delay was associated with a composite of adverse outcomes, including disease progression and death (95/424; 22.4% vs 601/3360; 17.9%; P=.024) compared with those who had operations within 8 weeks of tumor board decisions. One in 13 (189/2430; 7.9%) did not receive their planned operations, in whom 1 in 20 (5/189; 2.7%) died and 1 in 5 (34/189; 18%) experienced disease progression or death within 3 months of multidisciplinary team board decision for surgery. Only 22 of the 3778 surgical patients (0.6%) acquired perioperative SARS-CoV-2 infections; they had a longer postoperative stay (median 8.5 vs 4 days; P<.0001), higher predefined surgical morbidity (14/22; 63.6% vs 717/3762; 19.1%; P<.0001) and mortality (4/22; 18.2% vs 26/3762; 0.7%; P<.0001) rates than the uninfected cohort.ConclusionOne in 5 surgical patients with gynecologic cancer worldwide experienced management modifications during the COVID-19 pandemic. Significant adverse outcomes were observed in those with delayed or cancelled operations, and coordinated mitigating strategies are urgently needed.

Relationship between race and anemia in women undergoing surgery for gynecologic cancer.

e13529 Background: Anemia is associated with poor outcomes after gynecologic surgery and there is a paucity of data whether race modify its impact on outcome. The goal of this study is to estimate the anemia prevalence in women undergoing surgery for gynecologic cancer and to evaluate the relationship between preoperative anemia and postoperative morbidity and understand whether race and ethnicity modify this relationship. Methods: We performed a retrospective cohort study of patient’s undergoing surgery for a gynecologic malignancy between 2014 and 2019 using data from the National Surgical Quality Improvement Program. Multivariable logistic regression was used to determine adjusted odds for post operative morbidity with anemia. Interaction terms were entered into the model to test for effect modification by race and ethnicity. Results: We found that Black women were twice as likely to suffer from anemia then Caucasian women. In Caucasian women 79% had normal Hgb level, 16% mild anemia, 5% moderate anemia, and 0.5% with severe anemia. However, in Black women only 59% had normal Hgb level, with 30% having mild anemia, 10% moderate anemia, and 1% with severe anemia. We also found that the adjusted odds ratio of postoperative morbidity was higher in Black women with moderate and severe anemia than in Caucasian women. (Table). Logistic regression models to predict the probability of mortality for women with varying stages of anemia. Showing a difference in probability of morbidity between Black women and Caucasian women of undergoing gynecologic oncologic surgery. Conclusions: In this cohort of 56,240 patients who had surgery for a gynecologic malignancy we found that 24% had anemia. when treated may improve postoperative outcomes were more likely to have anemia than Caucasian women in this cohort. Black women had higher rates of postoperative morbidity at all levels of anemia, demonstrating continued disparities in care. Preoperative anemia is a modifiable risk factor that when treated may improve postoperative outcomes.[Table: see text]

Feasibility and Safety of Intraoperative Radiotherapy with Low Energy X-ray Photon Therapy for Recurrent Gynecological Cancer: A Case Series.

Objectives: To evaluate the feasibility and safety of low energy X-ray photon intraoperative radiotherapy (IORT) as an adjuvant therapy for recurrent gynecological cancer.Methods: Medical records of all recurrence gynecological cancer patients who underwent IORT were reviewed. Results: Between January 2018 and December 2021, five women (including cervical cancer (n = 2), endometrial cancer (n = 2), and uterine leiomyosarcoma (n = 1)), who underwent IORT and surgical resection for recurrent gynecologic cancer were reviewed. A median dose of 15.62 Gy (range, 12 to 20 Gy) was used for IORT. Repeated IORT and surgical resection was performed in two women. Three women experienced local recurrence, and three women died during follow-up. The 1-year local control rate was 60%. The 2-year overall survival rate was 30%. There was no Clavien–Dindo classification grade III–V complication. Conclusion: IORT using low energy X-ray photon therapy seems to be feasible and safe as an adjuvant therapy in women who underwent salvage surgery for recurrent gynecologic cancer. However, large-scale prospective studies are needed to confirm our findings and evaluate its efficacy.

Feasibility and Prediction of Adverse Events in a Postoperative Monitoring Program of Patient-Reported Outcomes and a Wearable Device Among Gynecologic Oncology Patients.

The objective of this study was to test the feasibility of implementing a postoperative monitoring program for women with gynecologic cancers composed of patient-reported outcomes (PROs) and a wearable activity monitor. We prospectively enrolled patients undergoing gynecologic cancer surgery to this single-arm study. Enrolled patients completed PROs (Patient-Reported Outcomes Measurement Information System physical function, sleep disturbance, anxiety, fatigue, and pain intensity) at baseline and one-week intervals for 4 weeks. They also wore a wearable accelerometer device that measured steps, heart rate, and intensity of physical activity. The primary outcome was feasibility. The secondary outcome was prediction of unscheduled contacts with the health care system on a given postoperative day. We enrolled 34 women. Three patients were unevaluable. The mean age was 58 years. The mean body mass index was 31 kg/m2; 17 patients were White (54.8%), 12 patients were Black (38.7%), and two patients (6.5%) were Asian. The overall wear time was 83.8%, and patients responded to 80.4% of the PRO instruments. Twenty-two patients (71%) had an unscheduled contact with the health care system postoperatively (median 1.5, 0.0-8.0). The day of an unscheduled health care utilization event was predicted with acceptable discrimination (area under the receiver operating characteristic curve 0.75; 95% CI, 0.67 to 0.81). PROs of fatigue and physical function were most predictive followed by wearable device outputs of lightly active minutes and average daily heart rate. Implementation of a postoperative monitoring program of patient-reported outcomes and a wearable device was feasible. The specific day of an unscheduled contact with the health care system was predicted with acceptable discrimination.

Optimizing Perioperative Venous Thromboembolism Chemoprophylaxis on a Gynecologic Oncology Service.

Perioperative venous thromboembolism (VTE) is a significant cause of morbidity and mortality after gynecologic cancer surgery. Here we report a quality improvement intervention to increase perioperative VTE chemoprophylaxis compliance. All operations performed by a gynecologic oncologist at a tertiary urban university medical center admitted to the hospital for at least one midnight were included. Using a pre/post design with a washout period, we sought to increase perioperative VTE chemoprophylaxis compliance from 22% in the historical control (HC) cohort to 90% in the quality improvement (QI) cohort. The perioperative VTE chemoprophylaxis process was standardized by addressing four domains: preoperative VTE chemoprophylaxis, surgical time-out, postoperative VTE chemoprophylaxis, and intervention education and compliance tracking. Pearson's chi-square test was used to compare HC vs QI cohort compliance. There were 130 surgical cases in the HC cohort and 131 in the QI cohort. Forty-two percent underwent laparotomy, and 57% had cancer at the time of operation. VTE chemoprophylaxis compliance improved from 22% in the HC cohort to 82% in the QI cohort (p < 0.001). Preoperative VTE chemoprophylaxis compliance improved from 76% in the HC cohort to 94% in the QI cohort (p < 0.001), and postoperative VTE chemoprophylaxis compliance improved from 27% to 87% (p < 0.001). Thirty-day postoperative VTE occurred in three patients (2%) in the HC cohort and none in the QI cohort (p = 0.08). A low-cost and low-technology QI initiative intervention improved perioperative compliance with VTE chemoprophylaxis.

National survey on the certification of competence in gynecologic surgical oncology: An AGOF (association of gynecologists in training) study

IntroductionFemale malignancies can require complex surgeries with expert techniques. A French certification of competence in gynecological cancer surgery has been elaborated in 2021 to certify specialized surgeons. For trainees, this would require a practical curriculum (number of rotations in certain departments), a surgical logbook and the theoretical European exam. The objective of our work was to interrogate trainees in gynecology and obstetrics on their oncological training and their opinion on the certification. Material and methodsWe conducted a national French prospective, observational study, using a web-based questionnaire from 06/2021–02/2022. All trainees were interrogated on their overall training in gynecological oncology. The opinion on the certification was assessed for the sub-group willing to specialize in oncological surgical gynecology. ResultsOne hundred and twenty-five responded, and 66.1% wanted to specialize in surgical oncology. Many had completed one rotation in a specialized gynecological oncology center (45.3%) and in digestive surgery (48.8%). Concerning the theoretical training, 92% of the respondents believed it to be insufficient. Eighty participants (64%) wished to specialize in oncological surgical gynecology and were interrogated on the certification. The majority (65%) thought the three criteria were difficult to achieve but adequate. The most difficult criterium was the practical curriculum (70.5%) followed by the surgical logbook (55.1%) due to inequalities of training amongst French regions. ConclusionTrainees in gynecology and obstetrics seem ready to take a specialized certification in surgical gynecological oncology to improve patient care. However, they expressed concerns due the disparities amongst regions in accessing certain specialized departments.

Laparoscopic approach for symptomatic pelvic and para-aortic lymphoceles

Description and demonstration of the feasibility of laparoscopic management of symptomatic pelvic lymphocele after surgical staging in gynecological cancer surgery. Step-by-step description of the surgical procedure using pictures and an educational video. Patient gave informed consent for the use of images and the full video article was approved by the Institutional Review Board of the Hospital of Sant Pau. Lymphocele is one of the most common complications of pelvic or lumbo-aortic lymphadenectomy. Although the incidence is variable at 1-58%, around 5-18% of cases are symptomatic. Only symptomatic lymphocele requires treatment, which can be medical or interventional. Drainage is usuallyperformed by guided radiology although a surgical approach has shown a lower rate of recurrence. A 64-years-old woman diagnosed withendometrial carcinosarcoma was staged laparoscopically by pelvic and para-aortic lymphadenectomy. Para-aortic lymphadenectomy wasperformed using an extraperitoneal approach. Three weeks later she presented with an intense and persistent burning pain, radiating towardsthe left leg. Computed tomography imaging suggested the presence of a 10x7.6 cm lymphocele adjacent to the left external iliac vessels.Laparoscopy was performed with four-port placement configuration, enabling the identification of a large, bilobed lymphocele, adjacent to theleft pelvic wall and left paracolic gutter. Adhesiolysis and identification of main landmarks in the left paracolic gutter and left paravesical fossawas performed as a first step. Peritoneum of each lymphocele was opened in the caudal region and the opening was broadened to facilitatelymph drainage. Owing to the low morbidity and excellent results, we suggest that laparoscopic drainage should be performed as a feasible anduseful treatment for pelvic symptomatic lymphoceles.

A prospective observational study assessing the feasibility and factors affecting same-day discharge in patients undergoing robotic-assisted surgery for gynecological cancers.

Although robotic-assisted surgery is being increasingly used in the management of gynecologic cancers, most surgeons discharge patients on the next day of surgery citing concerns about immediate post-operative complications. Present study was conducted to evaluate the safety, factors influencing and quality of life for gynaecological cancer patients undergoing same-day discharge after robotic-assisted surgery. This is single institutional prospective observational study as pragmatic cohort including all well-selected gynecological cancer patients undergoing robotic-assisted surgery from September 2017 to June 2019. Patients were divided into two study groups [Same-day discharge (SDD) group vs. Next-day discharge (NDD) group] according to day of discharge. The entire cohort included 152 patients (38 in SDD group and 114 in NDD group). The difference between both SDD vs. NDD was significant for parameters including Age ≥ 70years (0% vs. 18.4%, p: 0.010); Operative time > 60min (39.5% vs. 60.5%, p: 0.024); patients with third-party insurance covering surgery (2.6% vs. 25.4%, p: 0.005) and place of residence ≥ 60km from hospital (13.1% vs. 51.8%, p: < 0.0001). The quality of life was similar in both groups and none of the patients required readmission or emergency room visits. Same-day discharge after robot-assisted surgery in gynecologic cancer patients is a safe and feasible option. Younger patients, short surgical time, surgery early in the day, no claim for third-party insurance, residing nearby hospital within 60km radius were influencing factors favouring same-day discharge.

Computed Tomography-Based Quantitative Analysis of Fibrotic Changes in Skin and Subcutaneous Tissue in Lower Extremity Lymphedema Following Gynecologic Cancer Surgery.

Background: Lymphedema produces protein-rich fluids that aggravate inflammation in the skin and subcutaneous tissue. Inflammation then induces fibroadipose tissue deposition and fibrosis. However, few methods have been developed to evaluate the severity of fibrosis. Therefore, we aimed to evaluate the subcutaneous fibrotic changes in lower extremity lymphedema following gynecologic cancer surgery using an image analysis tool, the FIJI software. Methods and Results: Seventy-four patients with lymphedema following gynecologic surgery were enrolled in this study. We quantitatively analyzed the cross-sectional area (CSA) of soft tissue compartments, including subcutaneous tissue with the skin, muscle volume, fibrotic changes in subcutaneous tissue, and the perimeter of skin boundaries. The limb circumference and the CSA of the subcutaneous tissue and skin on the affected side were significantly larger than those on the unaffected side. Fibrotic changes showed the same trend. However, muscle volume patterns were different from those of the other compartments. Some patients showed lower muscle volume on the unaffected side than on the affected side. Circumference and cellulitis significantly affected the extent of fibrotic changes in the skin and subcutaneous tissues. Age and duration of lymphedema did not affect fibrosis. Conclusion: Fibrosis of subcutaneous regions with the skin can be quantitatively calculated using an image analysis tool in lower extremity lymphedema following gynecologic cancer surgery. Edema and cellulitis increase fibrotic changes in the subcutaneous tissue with the skin.

Quality of life from cytoreductive surgery in advanced ovarian cancer: Investigating the association between disease burden and surgical complexity in the international, prospective, SOCQER-2 cohort study.

ObjectiveTo investigate quality of life (QoL) and association with surgical complexity and disease burden after surgical resection for advanced ovarian cancer in centres with variation in surgical approach.DesignProspective multicentre observational study.SettingGynaecological cancer surgery centres in the UK, Kolkata, India, and Melbourne, Australia.SamplePatients undergoing surgical resection (with low, intermediate or high surgical complexity score, SCS) for late‐stage ovarian cancer.Main Outcome MeasuresPrimary: change in global score on the European Organisation for Research and Treatment of Cancer (EORTC) core quality‐of‐life questionnaire (QLQ‐C30). Secondary: EORTC ovarian cancer module (OV28), progression‐free survival.ResultsPatients’ preoperative disease burden and SCS varied between centres, confirming differences in surgical ethos. QoL response rates were 90% up to 18 months. Mean change from the pre‐surgical baseline in the EORTC QLQ‐C30 was 3.4 (SD 1.8, n = 88) in the low, 4.0 (SD 2.1, n = 55) in the intermediate and 4.3 (SD 2.1, n = 52) in the high‐SCS group after 6 weeks (p = 0.048), and 4.3 (SD 2.1, n = 51), 5.1 (SD 2.2, n = 41) and 5.1 (SD 2.2, n = 35), respectively, after 12 months (p = 0.133). In a repeated‐measures model, there were no clinically or statistically meaningful differences in EORTC QLQ‐C30 global scores between the three SCS groups (p = 0.840), but there was a small statistically significant improvement in all groups over time (p < 0.001). The high‐SCS group experienced small to moderate decreases in physical (p = 0.004), role (p = 0.016) and emotional (p = 0.001) function at 6 weeks post‐surgery, which resolved by 6–12 months.ConclusionsThe global QoL of patients undergoing low‐, intermediate‐ and high‐SCS surgery improved at 12 months after surgery and was no worse in patients undergoing extensive surgery.Tweetable Compared with surgery of lower complexity, extensive surgery does not result in poorer quality of life in patients with advanced ovarian cancer.

Artificial intelligence and lymphedema: State of the art

Lymphedema practice is facing many challenges. Some of these challenges include eradication of tropical lymphedema, preclinical diagnosis of cancer-related lymphedema, and delivery of appropriate individualized care. The past two decades have witnessed an increasing implementation of artificial intelligence (AI) in health-care services. The nature of the challenges facing the lymphedema practice is suitable for AI applications. The aim of this study was to explore the current AI applications in lymphedema prevention, diagnosis, and management and investigate the potential future applications. Four databases were searched: PubMed, Scopus, Web of Science, and EMBASE. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis as our basis of organization. Our analysis showed that several domains of AI, including machine learning (ML), fuzzy models, deep learning, and robotics, were successfully implemented in lymphedema practice. ML can guide the eradication campaigns of tropical lymphedema by estimating disease prevalence and mapping the risk areas. Robotic-assisted surgery for gynecological cancer was associated with a lower risk for the lower limb lymphedema. Several feasible models were described for the early detection and diagnosis of lymphedema. The proposed models are more accurate, sensitive, and specific than current methods in practice. ML was also used to guide and monitor patients during the rehabilitation exercises. AI offers a variety of solutions to the most challenging problems in lymphedema practice. Further, implementation into the practice can revolutionize many aspects of lymphedema prevention, diagnosis, and management. Lymphedema is a chronic debilitating disease that is affecting millions of patients. Developing new modalities for prevention, early diagnosis, and treatment are critical to improve the outcomes. AI offers a variety of solutions for some of the complexities of lymphedema management. In this systematic review, we summarize and discuss the latest AI advances in lymphedema practice.

Analysis of Distress in Patients with Gynecological Cancers During the COVID-19 Pandemic: A Telephone Survey

Objective: To investigate distress levels in patients with gynaecological cancers during the coronavirus disease-2019 (COVID-19) pandemic and identify factors associated with distress. Material and Methods: A total of 193 patients who underwent cytoreductive surgery for gynaecological cancer were included in our research. The patients were contacted by phone and provided detailed information about our study and the questionnaire that was to be applied. We performed distress screening using The National Comprehensive Cancer Network Distress Thermometer and Problem List (PL), developed for cancer patients. Results: In the study group, 51% of patients were categorized in the high-stress group. As practical problems, childcare (p<0.001), insurance/financial (p<0.033), work/school (p<0.001), treatment decisions (p<0.001), have significant differences between 2 groups in the present study. As family problems dealing with children (p<0.001), family health issues (p<0.014) have significant differences between the low-stress group and the high-stress group. All the emotional parameters evaluated by PL questionnaire have significant difference between the groups. The emotional significance levels of the parameters are as follows: depression (p<0.001), fears (p<0.001), nervousness (p<0.002), sadness (p<0.001), worry (p<0.012), loss of interest (p<0.001). Conclusion: Our results send a message to the gynaecological cancer healthcare world about what conditions may plague the gynaecological cancer patient in COVID-19 pandemic. Identifying problem areas for patients in our study constitutes the first step in the intervention.

Informed consent forms for gynecologic cancer surgery: recommendations from the Korean Society of Gynecologic Oncology.

The sociomedical environment is changing. In the traditional physician-patient relationship, the physician was authoritative and the patient was obedient. The contractual relationship featured patient consent to the physician’s decision. Today, the physician must explain fully the planned medical treatment, and any alternative, to the patient, who has the right to choose her treatment after considering the benefits and side-effects. The Korean Society of Gynecologic Oncology (KSGO) thus decided to standardize the surgical consent forms to meet the legal requirements of modern medicine, improve patient understanding of the surgical details, and protect medical staff from legal disputes. To determine the format and content, subcommittees for each cancer type collected and reviewed all relevant articles and the current consent forms of domestic medical institutions. After several meetings, 16 basic items to be included for each type of gynecologic cancer were selected. Also, to help patients understand the surgical details, figures were included. The revised forms were legally reviewed in terms of the appropriateness of the format and content. We also developed English versions to provide adequate information for foreign patients. We hope that these efforts will promote trust between patients and physicians, and contribute to effective treatment by laying a foundation of mutual respect.

Outcomes and resource utilization following surgery for gynecologic malignancies at safety-net hospitals across the United States

To evaluate the association between hospital safety-net status and surgical outcomes among a national sample of patients undergoing inpatient surgery for gynecologic cancers. We hypothesized safety-net hospitals (SNH) to be associated with increased utilization of open surgery, in-hospital mortality, and acute complications.

Reconstruction of pelvic exenteration and gynecologic tumor defects: a pictorial essay for a systematic method

Background: Reconstruction of the defects created by extirpative surgery or radiation for gynecologic cancer can be challenging for both patients and surgeons. In the subset of patients who present with recurrent gynecologic cancer after previously successful treatment and radiation therapy, wounds to irradiated tissue are difficult to heal, requiring a collaborative effort between the gynecologic oncologists and the plastic and reconstructive surgeons. Other factors that may hinder successful repair include comorbidities, history of radiation, ongoing tobacco use, and overall protein malnutrition. To maximize repair success, decrease recurrence, and optimize aesthetic outcome, gynecologic oncologists and plastic and reconstructive surgeons need to communicate the anticipated anatomic and physiologic obstacles to each other and to the patient. Purpose: To create a systematic approach from our current method of gynecologic oncologic reconstruction that facilitates communication among general surgeons, gynecologic oncologists, and plastic and reconstructive surgeons to optimize gynecologic oncologic reconstructive and aesthetic outcomes while minimizing wound complications. Methods: A retrospective chart review was conducted on patients who underwent gynecologic oncologic surgery for vulvar, vaginal, cervical, and uterine cancer over a 10-year period. A step-by-step method and categorization for gynecologic reconstruction was generated from our experience, and a pictorial essay was created to demonstrate this method and highlight the most common complications. Results: The pictorial essay serves as a template for gynecologic oncology or plastic and reconstructive surgeons to follow and effectively close gynecologic tumor defects and facilitate patient care. The most common complications were seroma and distal skin necrosis, managed by early excision and closure without consequence. Satisfaction with surgical outcomes was high among the patients. Conclusion: Successful repair of primary and recurrent gynecologic tumors requires communication between the gynecologic oncologist and the plastic and reconstructive surgeon. The procedures are challenging and require resilience from both the patient and the surgeons. Incision placement is important for adequate flap reconstruction to prevent wound and skin breakdown. Wound breakdown is likely and requires preoperative counseling. High protein nutritional stores are important for expeditious healing.

La certification de compétence en chirurgie cancérologique gynécologique au vu d’un parcours de formation

ObjectiveIn France, we are lacking an identified pathway for training in gynaecological cancer surgery. The four competent French learned societies, the SFOG, the CNGOF, the SFCO and the SCGP, supported by the CNU of Obstetrics &Gynaecology- and UNICANCER, agreed to materialize this course and attest it by a certification awarded by a national jury. Material and methodsThe national committee of certification in gynaecological oncology made up of 10 members, representing the 6 concerned organizations, set itself 5 objectives: the definition of the eligibility criteria for training centres; the determination of a check-list to be filled by the candidate; the determination of a targeted curriculum for the training in gynecological oncological surgery; the determination of the assets necessary for the certification of a candidate already in practice; and the practical organization of the certification. ResultsCriteria for approval of centres for training included 150 gynaecological cancer cases per year, among which 100 excisional surgeries, including 20 advanced-stage ovarian cancers. For certification of candidate who followed the curriculum established by the committee or by validation of prior experience for an actual practitioner, a candidate must validate a logbook and fill out a checklist including 4 parts: theoretical and practical training; research and publications; teaching and subscription to a continuing education program. The accomplished elements of the logbook and the checklist will be evaluated by a score. The first certification session is planned for the end of 2021. ConclusionThe optimisation of the surgical management of patients treated for gynaecological cancer is achieved through the identification of a training course and the certification, by a national jury, of the skills of surgeons who have completed it.

Microsurgical Lymphovenous Anastomosis for Pelvic Lymphoceles after Gynecological Cancer Surgery

Pelvic lymphoceles are the most common complications after pelvic lymphadenectomy. Microsurgical procedures have attracted attention as an alternative treatment for lymphoceles. Here, we report six cases of refractory lymphoceles that were successfully treated using lymphovenous anastomosis (LVA). Six patients underwent surgery for gynecological cancers and developed pelvic lymphoceles, which did not respond to conventional treatment. We mainly performed LVA on the ipsilateral lower limbs, although some procedures were also performed on the contralateral limbs. The change in the lymphocele volume after LVA was examined using computed tomography and compared using the Wilcoxon test. Five of the six refractory lymphocele cases were successfully treated using LVA, and the remaining case exhibited an 87% reduction in lymphocele volume. The average numbers of anastomoses were 6.7 on the ipsilateral side and 2.8 on the contralateral side (the median numbers: 6 [range: 5-9] vs. 3 [range: 1-4], P=0.034). The average lymphocele volume decreased significantly from 414.0mL preoperatively to 8.0mL postoperatively (the median lymphocele volume: 255.8 [range: 61.5-1,329.2] vs. 0 [range: 0-47.7], P=0.0313). We found that microsurgical treatment was potentially effective for lymphoceles that did not respond to conventional treatment.

Evaluating compliance of extended venous thromboembolism prophylaxis following abdominopelvic surgery for cancer: A multidisciplinary quality improvement project.

Despite quality evidence supporting postoperative extended venous thromboembolism prophylaxis (eVTEp) following abdominopelvic cancer surgery, baseline use of eVTEp at our institution was 3%. Our project aim was to improve the proportion of patients prescribed eVTEp following surgery for gynecologic, hepatobiliary, and colorectal cancers by a 30% absolute increase. We performed an interrupted time series study using quality improvement methodology. Postoperative order sets, pre-printed prescriptions, process checklists, and multimodal education were introduced. Process and outcome data were collected and analyzed on statistical process control charts. We included 324 patients with gynecologic and hepatobiliary cancers. Despite efforts to include them, the colorectal team did not participate. The monthly mean order set-use was 58% (SD = 14%), by specialty: gynecology 79%, hepatobiliary 47%. The proportion of patients prescribed eVTEp increased from 3% to 70% (SD = 14%). The target goal was surpassed and sustained by both cohorts. Patient compliance was 73% (n = 117/160, SD = 16%). Of those who stopped eVTEp early, 45% (n = 14/31) objected because of the injectable nature. Bleeding events were infrequent (0.6%, n = 2/324). Three process changes and multimodal education resulted in a significant increase in eVTEp use. Failure to identify improvement champions limited project expansion to colorectal patients. Patient compliance was largely limited by the injectable nature of the medication.