RESUMO
OBJECTIVE: The objectives of this Delphi study are to describe muscle relaxant and reversal practices in France and to seek a consensus on the impact of the reversal method on the time spent in the OR and PACU. METHOD: A two-round Delphi survey was conducted on a panel of French anesthetists involved in colectomies, hysterectomies or bariatric surgery. The questionnaire was designed in collaboration with a scientific committee and was intended to assess neuromuscular blockade reversal techniques and their impact on time spent in the OR and PACU. The first round gathered data on practices and the second round sought a consensus for the time aspect. RESULTS: Overall, all participants (99%) monitored neuromuscular blockade, with a majority (82%) doing so continuously. Of the participants, 22% routinely used a reversal drug. The time saved in the OR or PACU with sugammadex varied between 1 and 43 minutes depending on the surgery and the neuromuscular blockade reversal method it was compared to. CONCLUSION: Although SFAR recommendations (French Society of Anesthesia & Intensive Care Medicine) were generally well followed, the use of neuromuscular blockade reversal drugs was observed to be not fully integrated into regular practice, despite the fact that more than half of patients were reported to have residual neuromuscular blockade post-surgery and that sugammadex is known to reduce time spent in the OR and PACU compared to other neuromuscular blockade reversal methods.
Assuntos
Bloqueio Neuromuscular , Fármacos Neuromusculares não Despolarizantes , Preparações Farmacêuticas , gama-Ciclodextrinas , Técnica Delphi , Humanos , Músculos , Neostigmina , Bloqueio Neuromuscular/métodos , Salas CirúrgicasRESUMO
BACKGROUND: Prognostic impact of lymph node micro-metastases (pN1mi) has been discordantly reported in the literature. The need to clarify this point for decision-making regarding adjuvant therapy, particularly for patients with endocrine receptor (ER)-positive status and HER2-negative tumors, is further reinforced by the generalization of gene expression signatures using pN status in their recommendation algorithm. PATIENTS AND METHODS: We retrospectively analyzed 13 773 patients treated for ER-positive breast cancer in 13 French cancer centers from 1999 to 2014. Five categories of axillary lymph node (LN) status were defined: negative LN (pN0i-), isolated tumor cells [pN0(i+)], pN1mi, and pN1 divided into single (pN1 = 1) and multiple (pN1 > 1) macro-metastases (>2 mm). The effect of LN micro-metastases on outcomes was investigated both in the entire cohort of patients and in clinically relevant subgroups according to tumor subtypes. Propensity-score-based matching was used to balance differences in known prognostic variables associated with pN status. RESULTS: As determined by sentinel LN biopsy, 9427 patients were pN0 (68.4%), 546 pN0(i+) (4.0%), 1446 pN1mi (10.5%) and 2354 pN1 with macro-metastases (17.1%). With a median follow-up of 61.25 months, pN1 status, but not pN1mi, significantly impacted overall survival (OS), disease-free survival (DFS), metastasis-free survival (MFS), and breast-cancer-specific survival. In the subgroup of patients with known tumor subtype, pN1 = 1, as pN1 > 1, but not pN1mi, had a significant prognostic impact on OS. DFS and MFS were only impacted by pN1 > 1. Similar results were observed in the subgroup of patients with luminal A-like tumors (n = 7101). In the matched population analysis, pN1macro, but not pN1mi, had a statistically significant negative impact on MFS and OS. CONCLUSION: LN micro-metastases have no detectable prognostic impact and should not be considered as a determining factor in indicating adjuvant chemotherapy. The evaluation of the risk of recurrence using second-generation signatures should be calculated considering micro-metastases as pN0.
Assuntos
Neoplasias da Mama , Neoplasias da Mama/genética , Feminino , Humanos , Recidiva Local de Neoplasia , Prognóstico , Estudos Retrospectivos , Biópsia de Linfonodo SentinelaRESUMO
BACKGROUND: The outcomes of paraaortic lymphadenectomy were compared for the treatment of gynecological malignancies to identify the most appropriate surgical approach. METHODS: Our retrospective, multicentric study included 1304 patients who underwent paraaortic lymphadenectomy for gynecological malignancies. The patients were categorized into the following five groups based on treatment type: transperitoneal laparoscopy (group A, n = 198), extraperitoneal laparoscopy (group B, n = 681), robot-assisted transperitoneal laparoscopy (group C, n = 135), robot-assisted extraperitoneal laparoscopy (group D, n = 44), and laparotomy (group E, n = 246). RESULTS: The prevalence of cancer types differed according to the surgical approach: there were more ovarian cancers in group E and more cervical cancers in groups B and D (p < 0.001). Estimated blood loss was higher in group E (844.2 mL) than in groups treated with minimally invasive interventions (115.8-141.5 mL, p < 0.005). For infrarenal dissection, fewer nodes were removed in group C compared with the other approaches (16 vs. 21 nodes, respectively, p < 0.05). The average operative time ranged from 169 min for group A to 247 min for group E (p < 0.001). Length of hospital stay was 14 days for group E versus 3.5 days for minimally invasive procedures (p < 0.05). The early postoperative grade 3 and superior Dindo-Clavien complications occurred in 9-10% of the patients in groups B-D, 15% of the patients in group E, and only 3% and 4% for groups A and C, respectively. The most common complication was lymphocele. CONCLUSIONS: Laparotomy increases preoperative and postoperative morbidity. The robot-assisted transperitoneal approach demonstrated a poorer lymph node yield than laparotomy and extraperitoneal approaches.
Assuntos
Neoplasias dos Genitais Femininos , Laparoscopia , Robótica , Feminino , Neoplasias dos Genitais Femininos/cirurgia , Humanos , Laparotomia , Excisão de Linfonodo , Estudos Retrospectivos , Procedimentos Cirúrgicos RobóticosRESUMO
OBJECTIVE: The French national rare gynecological tumor network has been established to improve the quality of care through offering expertise in double reading histological diagnosis, reviewing cases and guiding management of these tumors through specialized multidisciplinary tumor boards and online clinical guidelines (www.ovaire-rare.com). The aim of this study is to evaluate the impact of the development and implementation of this network by assessing the conformity of medical practice with the guidelines concerning the granulosa cell tumors (GCTs). METHODS: This is a French nationwide study, including 463 patients (out of the 639 identified patients) with a definitive diagnosis of GCT between 2011 and 2016. Surgical practices were analyzed for conformity with the current guidelines (www.ovaire-rare.org). Medical records, surgical and pathological reports were systematically analyzed. Total conformity was defined by a conservative (unilateral salpingo-oophorectomy) or radical surgery (hysterectomy and bilateral salpingo-oophorectomy) including surgical staging (omentectomy, peritoneal biopsies and peritoneal cytology) according to the FIGO stage. Partial conformity referred to a conservative or radical surgery without surgical staging and non-conformity was defined as a non-optimal surgery as recommended by the guidelines. RESULTS: Median age at diagnosis was 49 years old (range 10-89). The median size of tumor was 94 mm (range 5-400). Radical surgery was performed in 240 patients (52%); while a fertility-sparing surgery was performed in 98 cases (21%). A surgical staging was performed in 76 cases (16%) and an evaluation of the endometrium in 289 cases (62%). Surgery was fully compliant with the guidelines in 65 patients (14%), partially compliant in 213 patients (46%), non-compliant in 137 patients (30%) and not assessable in 48 cases (10%). A statistically significant difference for compliance was observed in restaging surgery (p < 0,001), radical surgery (p = 0,017) and the period (before or after) of the implementation of the network (p < 0,001). Survival analyses did not allow us to demonstrate a significant difference in overall survival nor in PFS although there was a trend in favor of optimal surgery compared to incomplete/non optimal surgery. CONCLUSION: Surgical management's conformity to the guidelines increases over time from 2011 to 2016. According to this study, the implementation of a national network dedicated to rare gynecologic tumors seems to significantly improve the surgical management of the patients with ovarian granulosa cell tumors.
Assuntos
Tumor de Células da Granulosa/diagnóstico , Tumor de Células da Granulosa/cirurgia , Procedimentos Cirúrgicos em Ginecologia/normas , Neoplasias Ovarianas/diagnóstico , Neoplasias Ovarianas/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Estudos de Coortes , Feminino , França/epidemiologia , Tumor de Células da Granulosa/mortalidade , Fidelidade a Diretrizes , Procedimentos Cirúrgicos em Ginecologia/métodos , Procedimentos Cirúrgicos em Ginecologia/estatística & dados numéricos , Humanos , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Neoplasias Ovarianas/mortalidade , Doenças Raras/diagnóstico , Doenças Raras/cirurgia , Estudos Retrospectivos , Adulto JovemRESUMO
BACKGROUND: The Society of European Robotic Gynaecological Surgery (SERGS) aims at developing a European consensus on core components of a curriculum for training and assessment in robot assisted gynaecological surgery. METHODS: A Delphi process was initiated among a panel of 12 experts in robot assisted surgery invited through the SERGS. An online questionnaire survey was based on a literature search for standards in education in gynaecological robot assisted surgery. The survey was performed in three consecutive rounds to reach optimal consensus. The results of this survey were discussed by the panel and led to consensus recommendations on 39 issues, adhering to general principles of medical education. RESULTS: On review there appeared to be no accredited training programs in Europe, and few in the USA. Recommendations for requirements of training centres, educational tools and assessment of proficiency varied widely. Stepwise and structured training together with validated assessment based on competencies rather than on volume emerged as prerequisites for adequate and safe learning. An appropriate educational environment and tools for training were defined. Although certification should be competence based, the panel recommended additional volume based criteria for both accreditation of training centres and certification of individual surgeons. CONCLUSIONS: Consensus was reached on minimum criteria for training in robot assisted gynaecological surgery. To transfer results into clinical practice, experts recommended a curriculum and guidelines that have now been endorsed by SERGS to be used to establish training programmes for robot assisted surgery.
RESUMO
Adjuvant chemotherapy by carboplatin and paclitaxel is recommended for all high-grade ovarian and tubal cancers (FIGO stages I-IIA) (grade A). After primary surgery is complete, 6 cycles of intravenous chemotherapy (grade A) are recommended, or a discussion with the patient about intraperitoneal chemotherapy, according to her risk-benefit ratio. After complete interval surgery for FIGO stage III, hyperthermic intraperitoneal chemotherapy (HIPEC) can be proposed, in accordance with the modalities of the OV-HIPEC trial (grade B). In cases of postoperative tumor residue or in FIGO stage IV tumors, chemotherapy associated with bevacizumab is recommended (grade A).
Assuntos
Neoplasias das Tubas Uterinas/cirurgia , Neoplasias Ovarianas/cirurgia , Neoplasias Peritoneais/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Bevacizumab/uso terapêutico , Carboplatina/uso terapêutico , Quimioterapia Adjuvante , Neoplasias das Tubas Uterinas/tratamento farmacológico , Feminino , Preservação da Fertilidade , França , Humanos , Hipertermia Induzida , Neoplasias Ovarianas/tratamento farmacológico , Paclitaxel/uso terapêutico , Neoplasias Peritoneais/tratamento farmacológicoRESUMO
An MRI is recommended for an ovarian mass that is indeterminate on ultrasound. The ROMA score (combining CA125 and HE4) can also be calculated (grade A). In presumed early-stage ovarian or tubal cancers, the following procedures should be performed: an omentectomy (at a minimum, infracolic), an appendectomy, multiple peritoneal biopsies, peritoneal cytology (grade C), and pelvic and para-aortic lymphadenectomies (grade B) for all histologic types, except the expansile mucinous subtypes, for which lymphadenectomies can be omitted (grade C). Minimally invasive surgery is recommended for early-stage ovarian cancer, when there is no risk of tumor rupture (grade B). For FIGO stages III or IV ovarian, tubal, and primary peritoneal cancers, a contrast-enhanced computed tomography (CT) scan of the thorax/abdomen/pelvis is recommended (grade B), as well as laparoscopic exploration to take multiple biopsies (grade A) and a carcinomatosis score (Fagotti score at a minimum) (grade C) to assess the possibility of complete surgery (i.e., leaving no macroscopic tumor residue). Complete surgery by a midline laparotomy is recommended for advanced ovarian, tubal, or primary peritoneal cancer (grade B). For advanced cancers, para-aortic and pelvic lymphadenectomies are recommended when metastatic adenopathy is clinically or radiologically suspected (grade B). When adenopathy is not suspected and when complete peritoneal surgery is performed as the initial surgery for advanced cancer, the lymphadenectomies can be omitted because they do not modify either the medical treatment or overall survival (grade B). Primary surgery (before other treatment) is recommended whenever it appears possible to leave no tumor residue (grade B).
Assuntos
Neoplasias das Tubas Uterinas/diagnóstico , Neoplasias das Tubas Uterinas/cirurgia , Neoplasias Ovarianas/diagnóstico , Neoplasias Ovarianas/cirurgia , Neoplasias Peritoneais/diagnóstico , Neoplasias Peritoneais/cirurgia , Biomarcadores Tumorais/sangue , Neoplasias das Tubas Uterinas/patologia , Feminino , França , Humanos , Laparoscopia , Imageamento por Ressonância Magnética , Procedimentos Cirúrgicos Minimamente Invasivos , Metástase Neoplásica , Estadiamento de Neoplasias , Neoplasias Epiteliais e Glandulares/diagnóstico , Neoplasias Epiteliais e Glandulares/patologia , Neoplasias Epiteliais e Glandulares/cirurgia , Neoplasias Ovarianas/patologia , Assistência Perioperatória , Neoplasias Peritoneais/patologia , Tomografia Computadorizada por Raios XRESUMO
An MRI is recommended for an ovarian mass that is indeterminate on ultrasound. The ROMA score (combining CA125 and HE4) can also be calculated (Grade A). In presumed early-stage ovarian or tubal cancers, the following procedures should be performed: an omentectomy (at a minimum, infracolic), an appendectomy, multiple peritoneal biopsies, peritoneal cytology (grade C), and pelvic and para-aortic lymphadenectomies (Grade B) for all histologic types, except the expansile mucinous subtypes, for which lymphadenectomies can be omitted (grade C). Minimally invasive surgery is recommended for early-stage ovarian cancer, when there is no risk of tumor rupture (grade B). Adjuvant chemotherapy by carboplatin and paclitaxel is recommended for all high-grade ovarian and tubal cancers (FIGO stages I-IIA) (grade A). For FIGO stage III or IV ovarian, tubal, and primary peritoneal cancers, a contrast-enhanced computed tomography (CT) scan of the thorax/abdomen/pelvis is recommended (Grade B), as well as laparoscopic exploration to take multiple biopsies (grade A) and a carcinomatosis score (Fagotti score at a minimum) (grade C) to assess the possibility of complete surgery (i.e., leaving no macroscopic tumor residue). Complete surgery by a midline laparotomy is recommended for advanced ovarian, tubal, or primary peritoneal cancers (grade B). For advanced cancers, para-aortic and pelvic lymphadenectomies are recommended when metastatic adenopathy is clinically or radiologically suspected (grade B). When adenopathy is not suspected and when complete peritoneal surgery is performed as the initial surgery for advanced cancer, the lymphadenectomies can be omitted because they do not modify either the medical treatment or overall survival (grade B). Primary surgery (before other treatment) is recommended whenever it appears possible to leave no tumor residue (grade B). After primary surgery is complete, 6 cycles of intravenous chemotherapy (grade A) are recommended, or a discussion with the patient about intraperitoneal chemotherapy, according to her risk-benefit ratio. After complete interval surgery for FIGO stage III disease, hyperthermic intraperitoneal chemotherapy (HIPEC) can be proposed, in accordance with the modalities of the OV-HIPEC trial (grade B). In cases of postoperative tumor residue or in FIGO stage IV tumors, chemotherapy associated with bevacizumab is recommended (grade A).
Assuntos
Carcinoma/terapia , Neoplasias das Tubas Uterinas/terapia , Neoplasias Ovarianas/terapia , Neoplasias Peritoneais/terapia , Antineoplásicos/uso terapêutico , Carcinoma/diagnóstico , Carcinoma/patologia , Neoplasias das Tubas Uterinas/diagnóstico , Neoplasias das Tubas Uterinas/patologia , Feminino , França , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos , Neoplasias Ovarianas/diagnóstico , Neoplasias Ovarianas/patologia , Neoplasias Peritoneais/diagnóstico , Neoplasias Peritoneais/patologiaRESUMO
Adjuvant chemotherapy with carboplatin and paclitaxel is recommended for all high-grade ovarian or Fallopian tube cancers, stage FIGO I-IIA (grade A). After a complete first surgery, it is recommended to deliver 6 cycles of intravenous (grade A) or to propose intraperitoneal (grade B) chemotherapy, to be discussed with patient, according to the benefit/risk ratio. After a complete interval surgery for a FIGO III stage, the hyperthermic intra peritoneal chemotherapy (HIPEC) can be proposed in the same conditions of the OV-HIPEC trial (grade B). In case of tumor residue after surgery or FIGO stage IV, chemotherapy associated with bevacizumab is recommended (grade A). For BRCA mutated patient, Olaparib is recommended (grade B).
Assuntos
Carcinoma Epitelial do Ovário/terapia , Neoplasias Ovarianas/terapia , Fatores Etários , Biomarcadores Tumorais/análise , Carcinoma Epitelial do Ovário/patologia , Quimioterapia Adjuvante , Continuidade da Assistência ao Paciente , Neoplasias das Tubas Uterinas/patologia , Neoplasias das Tubas Uterinas/terapia , Feminino , Preservação da Fertilidade , França , Humanos , Hipertermia Induzida , Neoplasias Ovarianas/patologia , Neoplasias Peritoneais/patologia , Neoplasias Peritoneais/terapia , Sociedades MédicasRESUMO
BACKGROUND: Few studies of robotic nipple sparing mastectomy (NSM) were reported. We report feasibility of robotic NSM and determine standard surgical procedure and learning curve threefold. METHODS: A cohort of patients with robotic NSM for breast cancer was analyzed. Complications and post-operative hospitalization stay were reported. The same technic was used for all patients except for skin and nipple areolar complex (NAC) dissection. Differences between three surgical procedures of NAC dissection were analyzed: group 1, dissection with robotic scissors using coagulation; group 2, dissection with robotic scissors without coagulation; and group 3, dissection with non-robotic scissors and then robotic dissection. We explored possible effect of learning curve among patients from group 1 with the same surgical procedure. RESULTS: Twenty-seven NSM with immediate breast reconstruction for breast cancers, 22 invasive and 5 in situ, were performed, with robotic latissimus dorsi-flap (RLDF) only in 17 cases, RLDF and breast implant in 6 cases, and implant alone in 4 cases. Repartition according to 3 surgical procedure groups was 16, 5, and 6 patients. Mean time of surgery and anesthesia decrease according to groups 1 to 3. Among 16 patients from group 1, time of surgery and anesthesia decreased with learning curve. Post-operative hospitalization decreased from group 1 to 3. We reported a total of 11 complications, with significant difference between groups (10 for group 1). Skin complications were higher for group 1 in comparison with groups 2-3 (p = 0.02). CONCLUSION: Robotic NSM can be performed with a brief learning. Standardized technique is proposed with non-robotic scissors superficial dissection and then dissection with robot.
Assuntos
Neoplasias da Mama/cirurgia , Mastectomia Subcutânea/efeitos adversos , Mamilos , Tratamentos com Preservação do Órgão/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Adolescente , Adulto , Idoso , Estudos de Coortes , Dissecação/efeitos adversos , Dissecação/educação , Dissecação/métodos , Estudos de Viabilidade , Feminino , Humanos , Curva de Aprendizado , Tempo de Internação/estatística & dados numéricos , Mastectomia Subcutânea/educação , Mastectomia Subcutânea/instrumentação , Mastectomia Subcutânea/métodos , Pessoa de Meia-Idade , Duração da Cirurgia , Tratamentos com Preservação do Órgão/instrumentação , Tratamentos com Preservação do Órgão/métodos , Complicações Pós-Operatórias/etiologia , Procedimentos Cirúrgicos Robóticos/educação , Procedimentos Cirúrgicos Robóticos/instrumentação , Procedimentos Cirúrgicos Robóticos/métodos , Resultado do Tratamento , Adulto JovemRESUMO
Faced to an undetermined ovarian mass on ultrasound, an MRI is recommended and the ROMA score (combining CA125 and HE4) can be proposed (grade A). In case of suspected early stage ovarian or fallopian tube cancer, omentectomy (at least infracolonic), appendectomy, multiple peritoneal biopsies, peritoneal cytology (grade C) and pelvic and para-aortic lymphadenectomy are recommended (grade B) for all histological types, except for the expansive mucinous subtype where lymphadenectomy may be omitted (grade C). Minimally invasive surgery is recommended for early stage ovarian cancer, if there is no risk of tumor rupture (grade B). Laparoscopic exploration for multiple biopsies (grade A) and to evaluate carcinomatosis score (at least using the Fagotti score) (grade C) are recommended to estimate the possibility of a complete surgery (i.e. no macroscopic residue). Complete medial laparotomy surgery is recommended for advanced cancers (grade B). It is recommended in advanced cancers to perform para-aortic and pelvic lymphadenectomy in case of clinical or radiological suspicion of metastatic lymph node (grade B). In the absence of clinical or radiological lymphadenopathy and in case of complete peritoneal surgery during an initial surgery for advanced cancer, it is possible not to perform a lymphadenectomy because it does not modify the medical treatment and the overall survival (grade B). Primary surgery is recommended when no tumor residue is possible (grade B).
Assuntos
Carcinoma Epitelial do Ovário/terapia , Neoplasias Ovarianas/terapia , Algoritmos , Antineoplásicos/uso terapêutico , Biomarcadores Tumorais/análise , Antígeno Ca-125/análise , Carcinoma Epitelial do Ovário/diagnóstico por imagem , Carcinoma Epitelial do Ovário/patologia , Terapia Combinada , DNA de Neoplasias/sangue , Neoplasias das Tubas Uterinas/patologia , Neoplasias das Tubas Uterinas/terapia , Feminino , França , Humanos , Laparoscopia , Excisão de Linfonodo , Proteínas de Membrana/análise , Metástase Neoplásica/terapia , Estadiamento de Neoplasias , Neoplasias Ovarianas/diagnóstico por imagem , Neoplasias Ovarianas/patologia , Assistência Perioperatória , Neoplasias Peritoneais/patologia , Neoplasias Peritoneais/terapia , Proteínas/análise , Sociedades Médicas , Proteína 2 do Domínio Central WAP de Quatro DissulfetosRESUMO
The following recommendations cover the perioperative management of ovarian, Fallopian tube and primary peritoneal cancers. Five questions related to pre-habilitation and enhanced recovery after surgery were evaluated. The conclusions and recommendations are based on an analysis of the level of evidence available in the literature. These recommendations are part of the overall recommendations for improving the management of ovarian, fallopian or primary peritoneal cancer, made with the support of INCa (Institut National du Cancer). The main preoperative measures are screening for nutritional deficiencies (Grade B) and for anaemia (GradeC) in patients with ovarian cancer. It is not possible to make recommendations on the correction of malnutrition and/or anemia or on the contribution of pre-operative immuno-nutrition due to the absence of data in ovarian cancer, tube cancer or primary peritoneum cancer. For the same reasons, no recommendation can be made on the value of preoperative digestive preparation in ovarian, fallopian tube or primary peritoneum cancer. During surgery, goal-directed fluid therapy for patients with advanced ovarian cancer is recommended (Grade B). A single dose infusion of tranexamic acid is recommended for patients with ovarian, fallopian tube or primary peritoneal cancer (GradeC). For postoperative analgesia, epidural analgesia is recommended for patients undergoing cyto-reduction surgery by laparotomy (Grade B). In the absence of epidural analgesia, patient controlled analgesia with morphine without continuous infusion (Grade B) is recommended. No recommendation can be given regarding intravenous administration of lidocaine and/or ketamine during surgery, or, regarding peri-operatively prescription of gabapentin or pregabalin. In the absence of studies on the impact of different non-opiate analgesic combinations for ovarian cancer surgery, no recommendations can be made. Early oral feeding is recommended, including in cases of digestive resection (Grade B). The implementation of enhanced recovery programs, including early mobilization, is recommended (GradeC).
Assuntos
Carcinoma Epitelial do Ovário/cirurgia , Neoplasias Ovarianas/cirurgia , Analgesia Controlada pelo Paciente , Anemia/etiologia , Anemia/terapia , Antifibrinolíticos/uso terapêutico , Perda Sanguínea Cirúrgica/prevenção & controle , Ingestão de Alimentos , Feminino , França , Humanos , Ileostomia , Desnutrição/prevenção & controle , Apoio Nutricional , Dor Pós-Operatória/prevenção & controle , Cuidados Pós-Operatórios , Cuidados Pré-Operatórios , Sociedades Médicas , Ácido Tranexâmico/uso terapêuticoRESUMO
INTRODUCTION: The objective of this study was to report a 30-year experience of PE for gynecologic malignancies in a cancer center. MATERIALS AND METHODS: A retrospective study was conducted at Institut Paoli-Calmette including patients who underwent PE for gynecologic malignancies. Four periods were evaluated: P1 before 1992, P2 between 1993 and 1999, P3 between 2000 and 2006 and P4 after 2006. The study evaluated the number of PE performed during each period, the type of PE, its level, indication, location of the primary tumor, patient age, previous radiotherapy ≥45â¯Gy, the rate of "curative" PE and exenteration-related reconstructive techniques. 90-day post-operative mortality and morbidity using the National Cancer Institute's Common Terminology Criteria for Adverse Events (NCI-CTCAE) v 4.03 were reported. RESULTS: 277â¯PE were performed. The number of PE performed for recurrences rose during the study period (pâ¯=â¯0.042), PE performed for central tumors increased during P3 (64.4%) and P4 (67.4%) (pâ¯<â¯0.0001) and administration of radiotherapy ≥45â¯Gy was more frequent (pâ¯<â¯0.0001). The rate of "curative" PE increased (pâ¯<â¯0.0001). In multivariate analysis, "curative" PE were correlated with PE type, central locations and study period. Pelvic filling was progressively more frequently performed (pâ¯=â¯0.002). 90-day complication rate was 56.3%. In multivariate analysis there was a significant difference in distribution of CTCAE grade 3-4-5 morbidity depending on the period. Overall survival (OS) improved during the 2 last periods (pâ¯=â¯0.008). CONCLUSION: A better selection of eligible patients for PE, namely through improvement in imaging techniques, has enabled to raise the rate of curative PE.
Assuntos
Neoplasias dos Genitais Femininos/cirurgia , Exenteração Pélvica/métodos , Adulto , Idoso , Feminino , Neoplasias dos Genitais Femininos/diagnóstico por imagem , Humanos , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/cirurgia , Seleção de Pacientes , Complicações Pós-Operatórias/epidemiologia , Procedimentos de Cirurgia Plástica , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do TratamentoRESUMO
Over the past 20 years, feasibility of laparoscopic approaches has been validated in gynecologic surgery. This procedure has specific challenges due its longer learning curve and the limits imposed by the technique. For the surgical treatment of recurrent pelvic cancers or locally advanced tumors, open surgery remains the gold standard for most surgical teams. Robotic assistance could be an interesting alternative. The aim of this study is to present our department's robotic surgical procedures in this specific field and show its feasibility and reproducibility on several patients.
Assuntos
Neoplasias dos Genitais Femininos/cirurgia , Procedimentos Cirúrgicos em Ginecologia/métodos , Laparoscopia/métodos , Recidiva Local de Neoplasia/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Adulto , Feminino , HumanosRESUMO
BACKGROUND: Pelvic exenteration remains one of the most mutilating procedures, with important postoperative morbidity, an altered body image, and long-term physical and psychosocial concerns. This study aimed to assess quality of life (QOL) during the first year after pelvic exenteration for gynecologic malignancy performed with curative intent. METHODS: A French multicentric prospective study was performed by including patients who underwent pelvic exenteration. Quality of life by measurement of functional and symptom scales was assessed using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 (version 3.0) and the EORTC QLQ-OV28 questionnaires before surgery, at baseline, and 1, 3, 6, and 12 months after the procedure. RESULTS: The study enrolled 97 patients. Quality of life including physical, personal, fatigue, and anorexia reported in the QLQ-C30 was significantly reduced 1 month postoperatively and improved at least to baseline level 1 year after the procedure. Body image also was significantly reduced 1 month postoperatively. Global health, emotional, dyspnea, and anorexia items were significantly improved 1 year after surgery compared with baseline values. Unlike younger patients, elderly patients did not regain physical and social activities after pelvic exenteration. CONCLUSIONS: Therapeutic decision on performing a pelvic exenteration can have a severe and permanent impact on all aspects of patients' QOL. Deterioration of QOL was most significant during the first 3 months after surgery. Elderly patients were the only group of patients with permanent decreased physical and social function. Preoperative evaluation and postoperative follow-up evaluation should include health-related QOL instruments, counseling by a multidisciplinary team to cover all aspects concerning stoma care, sexual function, and long-term concerns after surgery.
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Imagem Corporal , Neoplasias dos Genitais Femininos/cirurgia , Exenteração Pélvica/psicologia , Exenteração Pélvica/reabilitação , Qualidade de Vida , Adulto , Idoso , Feminino , Seguimentos , Neoplasias dos Genitais Femininos/patologia , Neoplasias dos Genitais Femininos/psicologia , Humanos , Pessoa de Meia-Idade , Período Pós-Operatório , Prognóstico , Estudos Prospectivos , Inquéritos e QuestionáriosRESUMO
Intravenous leiomyomatosis has an unusual growth pattern characterized by proliferation of smooth muscle in uterine and systemic veins. Although histologically benign, this condition could eventually have a clinically aggressive course. At an early stage, the disease is often misdiagnosed on preoperative imaging because of its low prevalence, non-specific initial clinical manifestation, and poorly known radiological characteristics. An early, accurate diagnosis is needed for appropriate surgical management that could result in a good prognosis, reducing the risk of recurrence and morbidity. Magnetic resonance imaging is a particularly valuable technique for assessing intravenous leiomyomatosis preoperatively.
Assuntos
Leiomiomatose/diagnóstico por imagem , Útero/irrigação sanguínea , Neoplasias Vasculares/diagnóstico por imagem , Diagnóstico Diferencial , Feminino , Humanos , Leiomiomatose/patologia , Leiomiomatose/cirurgia , Pessoa de Meia-Idade , Prognóstico , Neoplasias Vasculares/secundário , Neoplasias Vasculares/cirurgiaRESUMO
AIMS: To compare survival outcomes after mastectomy (Mt) and lumpectomy plus interstitial brachytherapy (LpIB) in the treatment of breast cancer local recurrence (LR) occurring after conservative surgery. METHODS: Medical records of patients treated for an isolated LR from January 1, 1981 to December 31, 2009 were reviewed. To overcome the bias due to the fact that treatment choice (Mt or LpIB) was based on prognostic factors with LpIB proposed preferentially to women with good prognosis, Mt and LpIB populations were matched and compared with regard to overall survival (OS) and metastasis free survival (MFS). RESULTS: Among 348 patients analyzed, 66.7% underwent Mt, 17.8% LpIB and 15.5% Lp alone. After a median follow-up of 73.3 months, 65 patients had died (42/232 Mt, 8/62 LpIB, 15/54 Lp). Before matching, OS and MFS at 5 years were significantly better in the LpIB compared to the Mt group, due to significantly more frequent poor prognostic factors in the latter (p = 0,07 and p = 0,09 respectively, log-rank significance limit of 10%). After matching, the benefits of LpIB disappeared since MFS and OS rates were not significantly different in both groups (p = 0.68 and 0.88 respectively). After LpIB, the second LR rate was 17% at 5 years and 30% at 10 years. CONCLUSION: A second conservative breast cancer treatment associating lumpectomy and interstitial brachytherapy is possible for selected patients with LR, without decrease in neither OS nor MFS compared to mastectomy.
Assuntos
Neoplasias da Mama/mortalidade , Neoplasias da Mama/terapia , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/terapia , Braquiterapia , Neoplasias da Mama/patologia , Feminino , Humanos , Mastectomia , Mastectomia Segmentar , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/patologia , Prognóstico , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
The aim of this study is to analyze the feasibility of ambulatory hospitalization or 24hours hospitalization for breast cancer treatment by mastectomy, as well as the satisfaction and the preferences of patients with regard to these ways of hospitalization. METHODS: This observational retrospective study listed the patients operated for breast cancer who had required a mastectomy at the institute Paoli-Calmettes between the 1st of January 2013 and June 30th, 2015. A questionnaire of satisfaction was proposed to the patients regarding their mode of hospitalization. RESULTS: One hundred and thirteen patients were included among which 29 were in the ambulatory group and 84 in the 24hours hospitalization group. The complications were represented by the rate of hematomas (3.5 %), which required a surgical resumption for two of the patients in the 24hours hospitalization group and for one patient in the ambulatory group (P=0.75). Patient's satisfaction rate was globally high: 72.7 % regardless of the mode of hospitalization (P=0.064). CONCLUSION: The realization of mastectomy in ambulatory hospitalization seems feasible when the organization in pre- and postoperative is anticipated with a high degree of satisfaction of the patients. The psychological impact of this radical surgery seems to be a factor to be taken into account and requires a meticulous selection of the patients.
Assuntos
Procedimentos Cirúrgicos Ambulatórios/estatística & dados numéricos , Neoplasias da Mama/cirurgia , Hospitalização/estatística & dados numéricos , Mastectomia/métodos , Preferência do Paciente/estatística & dados numéricos , Satisfação do Paciente , Idoso , Neoplasias da Mama/psicologia , Estudos de Viabilidade , Feminino , Humanos , Mastectomia/efeitos adversos , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos RetrospectivosRESUMO
OBJECTIVE: This study aims to evaluate the different surgical approaches, perioperative morbidity and surgical staging according to age in patients with endometrial cancer. METHODS: Multicentre retrospective study. Cancer characteristics and perioperative data were collected for patients surgically treated for endometrial cancer. The patients were divided into 2 groups according to their age: younger or older than 75 years. RESULTS: Surgery was performed on 270 women <75 years old and on 74 ≥ 75 years old. Minimally invasive surgery was performed less often in the elderly compared with their younger counterparts (58.2% vs. 74.8%; p = 0.006). Independently of the surgical approach, the rate of pelvic and para-aortic lymphadenectomy was lower in women older than 75 years old than their younger counterparts (52.7% vs. 74.8%; p < 0.001; 8.1% vs. 21.8%; p = 0.007 respectively). According to the guidelines, more frequent surgical understaging was seen in the elderly compared with the younger (37% vs. 15.2%; p = 0.002). In the comparison of complications for each surgical approach, there was no statistical difference in the ≥75-year-old age group in terms of intra- or postoperative complications between the laparotomy, laparoscopy or robotic surgery group. We found a shorter length of hospital stay for the women who underwent laparoscopy or robotic surgery compared with laparotomy (p < 0.0001). CONCLUSION: Elderly women with endometrial cancer are often surgically understaged whereas there is no evidence of greater perioperative complications than for their younger counterparts. They should benefit from minimally invasive surgery and optimal surgical staging to the same extent as younger women.