Endometriosis: seeking optimal management in women approaching menopause.

The incidence of endometriosis in middle-aged women is not minimal compared to that in the reproductive age group. The treatment of affected women after childbearing age to the natural transition toward menopause has received considerably poor attention. Disease management is problematic for these women due to increased contraindications regarding hormonal treatment and the possibility for malignant transformation, considering the increased cancer risk in patients with a long-standing history of the disease. This state-of-the-art review aims for the first time to assess the benefits of the available therapies to help guide treatment decisions for the care of endometriosis in women approaching menopause. Progestins are proven effective in reducing pain and should be preferred in these women. According to the international guidelines that lack precise recommendations, hysterectomy with bilateral salpingo-oophorectomy should be the definitive therapy in women who have completed their reproductive arc, if medical therapy has failed. Strict surveillance or surgery with removal of affected gonads should be considered in cases of long-standing or recurrent endometriomas, especially in the presence of modifications of ultrasonographic cyst patterns. Although rare, malignant transformation of various tissues in endometriosis patients has been described, and management is herein discussed.

[Delivery induction with slow-release dinoprostone in clinical practice: results of a clinical protocol]. / L'induzione del parto con prostaglandine a lento rilascio nella pratica clinica: risultati di un protocollo clinico.

AIM: The aim of this paper was to evaluate the feasibility of a protocol for the induction of delivery with slow-release dinoprostone in women with unfavourable cervix. METHODS: Indications for the induction were: pregnancy beyond 40 weeks, amniotic fluid index (AFI) <5, premature rupture of membranes, intrauterine growth retardation, or adverse maternal conditions. Eligibility criteria were: single pregnancy, cephalic presentation, Bishop Score <4, no previous uterine scar. Slow-release vaginal insert containing dinoprostone 10 mg was used to induce delivery according to a dedicated protocol agreed between clinicians and midwifes. Dinoprostone induction failure was defined as no cervical dilation >3 cm at the removal of the insert. RESULTS: One-hundred-nineteen patients were enrolled. The onset of labour was obtained in 102 (85.7%) patients, 98 (82.3%) with the insert only, and in 4 (3.3%) after the sequential administration of prostaglandins and oxitocin. The mean interval between insert application and delivery was 16.85±11.48 hours. Vaginal delivery was reported in 87 (73.1%) women, whereas Cesarean was necessary in 32 (26.9%) patients [29 nulliparous]. Cesarean section was also required in 15/98 (15.3%) women who responded to prostaglandins and in 17/21 (80.9) non-responders. Protocol violations occurred in 11 (9.2%) patients. Uterine hyperstimulation occurred in 4 (3.3%) patients. CONCLUSION: Induction of delivery with slow-release dinoprostone seems a feasible option, characterized by high efficacy, good adherence to protocol, low incidence of adverse events and easy management. In our opinion the high compliance of the gynecologists and midwifes is based on the insert handiness.

'Guess who'? An Italian multicentric study on pigmentation traits prevalence in endometriosis localizations.

OBJECTIVES: Previous evidence seems to support the more common presence of certain pigmentation types in women with endometriosis. The aim of this study was to assess the association of certain somatic phenotypes with specific localizations of the disease. The genetic makeup of those somatic traits may will help in better define the disease pathogenesis. STUDY DESIGN: Multicentric, retrospective study of women aged 18 to 45 with histologically confirmed endometriosis. 575 patients were recruited at eleven different Italian endometriosis clinics from March 2015 to January 2021. Data regarding clinical and surgical features were recorded following the self-administered endometriosis patient questionnaire and the surgical standard of reports approved by the World Endometriosis Research Foundation (WERF). Pigmentation types/somatic phenotypes frequencies among endometriosis localizations were reported. A logistic regression analysis was performed to determine somatic types independently associated with disease' localizations. RESULTS: Having green eyes increased by ∼4 folds (OR 3.7; 95% CI: 1.42-9.61; p = 0.007) the risk of having a ureteral nodule, whereas brown/black eyes decreased this risk (OR 0.34; 95% CI: 0.13-0.87; p = 0.025). Consistently, the combination of green eyes and blonde/light brown hairs increased the odds of ureteral endometriosis by more than 5 folds (OR 5.40; 95%CI: 2.02-14.49; p = 0.001), even after correction for anthropometric confounders (aOR 5.85; 95% CI: 2.13-16.09; p < 0.001). CONCLUSIONS: The association between endometriosis and pigmentary traits has been herein confirmed, with the novel finding of the possible predisposition of ureteral endometriosis in patients with green eyes and blonde/light brown hairs. Further investigation on the genetic makeup of somatic traits may provide new inroads also into the molecular aspects of endometriosis leading to a better understanding of this complex disease.

Minilaparotomic myomectomy for large symptomatic uterine myomas: a prospective study.

AIM: The aim of this paper was to evaluate the feasibility, morbidity, and reproductive performance of fertile women undergoing minilaparotomic myomectomy for large uterine myomas. METHODS: Ninety-nine consecutive women with symptomatic myomas underwent myomectomy through a skin incision ≤8 cm. Operative, postoperative and reproductive data were prospectively collected. RESULTS: Median (range) age and Body Mass Index (BMI) were 37 years (23-44) and 23 (18-43), respectively. Median (range) myoma diameter was 7 cm (4-20), and the median number of myomas removed was 1 (range 1-31). Myomas were intramural in 76 (76%) cases. Median incision length was 7 cm (range 4-13) and median duration of surgery was 70 min (range 40-180). Operative time and length of skin incision were not correlated with the progressive number of interventions. An incision larger than 8 cm was necessary in 7 (7%) patients and the length of incision was significantly correlated with the diameter of the largest myoma (P<0.01). The feasibility of minilaparotomy was significantly reduced when the diameter of the largest myoma was >12 cm (P<0.05). Operative time was significantly longer in patients having >1 myoma (P<0.05). Three (3%) patients underwent blood transfusion. Median (range) postoperative stay was 2 days (range 2-12). Fever occurred in 8 (8%) patients, and wound complications in 5 (5%). CONCLUSION: Myomectomy by minilaparotomy is a feasible procedure in more than 90% of unselected patients with large symptomatic myomas. Feasibility is questionable when the myoma is >12 cm. This technique is a mini-invasive option to treat patients with large and multiple myomas.

Endometrial carcinoma: intraoperative evaluation of myometrial invasion. A prospective study.

AIM: The authors investigated the diagnostic value of intraoperative assessment of myometrial invasion in endometrial cancer patients. Following hysterectomy, the uterus was sectioned and macroscopically examined in order to assess the depth of myoinvasion, which was classified as <50% and >50%. In patients with macroscopic depth of invasion>30% and <50%, a frozen section of this area was carried out. The results of intraoperative evaluation were compared with the results of postoperative pathological examination. The agreement between methods was developed as generalized Kappa type statistic. Sensitivity, specificity, positive and negative predictive values for intraoperative only macro and macro/micro evaluation were calculated. METHODS: Seventy eight consecutive patients (median age 64 years, range 43-92; median Body Mass Index [BMI] 30.5, range 21.9-46.7) who underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy (THBSO) were included in the study. Following intraoperative macroscopic evaluation, frozen section was carried out in 15 (19%) patients. The median time to obtain the results was 16 min for macroscopic evaluation, and 29 min for the macro/micro assessment. RESULTS: Macroscopic only assessment correctly identified depth of myoinvasion in 91% of patients, while, when the frozen section was carried out, myoinvasion was correctly identified in 95% of patients. For macroscopic only and macro-micro assessment sensitivity and specificity were 76% and 98%, 86% and 98%, respectively. CONCLUSION: These data suggest that the frozen section may improve, the diagnostic value of macroscopic only intraoperative assessment of myometrial invasion in selected patients.

Laparoscopic surgery in the treatment of stage I adult granulosa cells tumors of the ovary: Results from the MITO-9 study.

OBJECTIVE: Surgery represents the mainstay of treatment of stage I adult type granulosa cell tumors of the ovary (AGCTs). Because of the rarity and indolent course of the disease, no prospective trials are available. Open surgery has long been considered the traditional approach; oncological safety of laparoscopy is only supported by small series or case reports. The aim of this study was to compare the oncological outcomes between laparoscopic and open surgery in stage I AGCTs treated within the MITO (Multicenter Italian Trials in Ovarian cancer) Group. METHODS: Data from patients with stage I AGCTs were retrospectively collected. Clinicopathological features were evaluated for association with relapse and death. Survival curves were calculated using the Kaplan-Meier method and compared with the log-rank test. The role of clinicopathological variables as prognostic factors for survival was evaluated using Cox's regression model. RESULTS: 223 patients were identified. Stage 1A, 1B and 1C were 61.5%, 1.3% and 29.6% respectively. 7.6% were apparently stage I. Surgical approach was laparoscopic for 93 patients (41.7%) and open for 130 (58.3%). 5-years DFS was 84% and 82%, 10-years DFS was 68% and 64% for the laparoscopic and open-group (p = 0.6).5-years OS was 100% and 99%, 10 years OS was 98% and 97% for the laparoscopic and open-surgery group (p = 0.8). At multivariate analyses stage IC, incomplete staging, site of primary surgery retained significant prognostic value. CONCLUSION: The present study suggests that surgical route does not affect the oncological safety of patients with stage I AGCTs, with comparable outcomes between laparoscopic and open approach.

Insulin resistance and insulin deficiency in diabetic retinopathy of non-insulin-dependent diabetes.

To assess the role of insulin resistance and insulin deficiency in the pathogenesis of diabetic retinopathy in non-insulin-dependent diabetes mellitus, 13 patients with and 12 patients without retinopathy were studied. The glucose clamp technique was used to measure insulin resistance and insulin response to glucose. During the euglycemic clamp, at comparable steady-state levels of glucose and insulin, the mean glucose infusion rate, which indicates the rate of glucose utilization, was lower in the retinopathy group than in the nonretinopathy group (6.1 +/- 0.5 versus 8.1 +/- 0.7 mg . kg-1 . min-1, P less than 0.02). Growth hormone (GH) concentrations were higher in the retinopathy group 8.4 +/- 2.5 versus 2.5 +/- 0.7 microIU/ml, P less than 0.05), but they did not correlate significantly with insulin resistance, expressed as mean glucose turnover. During the hyperglycemic clamp (+7 mmol/L above the fasting plasma glucose), the insulin response in the two groups of diabetics was similar. Increased insulin resistance represents an additional factor, which together with other factors, may be important in the pathogenesis of diabetic microvascular complications.

Quantitative evaluation of fluorescein angiograms: microaneurysm counts.

This study describes a method for quantifying microaneurysms (MA) from fluorescein angiograms. The method was validated by the reproducibility of the number of MA in 30 angiograms read twice each by two independent observers; and by the absolute difference in MA counts between two readings by the same observer, and difference in numbers counted by two different observers. The precise location of each MA on two readings was also studied and the reproducibility of location varied from 60 to 71%, depending on the quality of the angiograms. Clinicians and technicians working in the same or in different centers obtained similar results. The coefficient of correlation between observers and between readings was satisfactory, r greater than 0.9. The method is easy to learn and the reproducibility allows for its use in clinical trials.

The relationship of hand abnormalities to diabetes and diabetic retinopathy.

The hands of 299 diabetic patients with and 161 without retinopathy were examined for abnormalities. Almost all abnormalities were finger joint contractures resulting in limited joint mobility (LJM) and/or Dupuytren's contractures (DC). Both LJM and DC occurred not only in insulin-dependent diabetes (IDDM) but also in non-insulin-dependent diabetes (NIDDM). In retinopathy patients LJM and DC occurred in 48% and 36% of patients, respectively, compared with 24% and 16% in those without retinopathy. These differences were statistically significant (P less than 0.001). The higher prevalence of LJM in the retinopathy group affected mainly those with severe retinopathy, there being no difference between background and nonretinopathy patients. DC was less clearly related to severe retinopathy. LJM was more severe in those with than without retinopathy. LJM and DC were also related to age and duration of known diabetes. Subgroups matched for age and duration of known diabetes showed that the main relationship of hand abnormalities was to retinopathy in IDDM, but more to age and duration of known diabetes in NIDDM.

Successful treatment of immune-mediated insulin resistance by human insulin (recombinant DNA).

An 82-yr-old woman with type II diabetes developed antibody-mediated insulin resistance while on mixed pork-beef insulin concomitantly with a non-Hodgkin lymphoma. Insulin resistance was initially treated with highly purified pork insulin, but this was unsuccessful. Treatment with human insulin (recombinant DNA) was associated with marked decrease of both insulin requirement and high-affinity antibodies, increase of free insulin levels, and improvement of diabetic control. This patient's case shows that human insulin can be considered as an alternative treatment for immune-mediated insulin resistance.

Changes in insulin resistance with long-term insulin therapy.

Thirteen newly diagnosed diabetic subjects, 5 with insulin-dependent diabetes mellitus (IDDM) and 8 with non-insulin-dependent diabetes mellitus, mean age 37.1 yr (range 25-64 yr), underwent glucose-clamp studies at diagnosis of diabetes at plasma glucose 200 mg/dl. Each subject was then treated twice daily with insulin for 6 mo with improvement in glycemic control, and the glucose-clamp studies repeated. Changes in glucose uptake at an insulin infusion rate of 1.0 mU X kg-1 X min-1 varied greatly from diagnosis to 6 mo. There were significant negative correlations between change in glucose uptake and diabetes type (r = -.78, P less than .002), C-peptide secretion (r = -.66, P less than .05), and age (r = -.62, P less than .05). At an insulin infusion rate of 10 mU X kg-1 X min-1 there was improvement in glucose uptake from diagnosis to 6 mo that did not reach statistical significance. During the steady-state periods of the glucose-clamp studies at diagnosis, growth hormone (GH) rose above basal, which reached statistical significance at the higher insulin infusion rate. This increase in GH was not apparent at the time of the glucose-clamp studies after insulin therapy. Our results indicate that in the clinical situation, only patients with IDDM can expect an improvement in their sensitivity to physiologic insulin levels with long-term insulin therapy. In all subjects, improvement in glycemic control leads to abolition of GH secretion in the presence of hyperglycemia.

Cesarean 10-group classification: a tool for clinical management of the delivery ward.

AIM: Aim of the present study was to evaluate 10-group Robson classification for delivery ward clinical management. METHODS: To evaluate cesarean section (C-section) rate following the implementation firstly of recommendations, and then of 10-group reporting and medical audit, a retrospective cohort study was performed including all women who gave birth in the years 2001, 2006 and 2010. Data were analyzed by means of 10-group classification. RESULTS: C-section rate was 27.5% in 2001, 31.1% in 2006, and 30.5% in 2010. Ten-group analysis showed that from 2001 to 2006 group 1-2 size increased from 27.6% to 42.5% (P<0.01), and contribution to the overall cesarean rate from 22.3% to 29.9% (P<0.01), whereas the group 1 C-section sub-rate was reduced from 19.6% to 13.5% (P<0.05). Previous cesarean increased from 9.2% to 11.6% (P<0.05). Delivery ward 10-group monitoring showed that from January to May 2010 the C-section rate was consistently above 30%. The audit was started and the causes were analyzed. Subsequently, C-section rate dropped to the actual 30.5%. CONCLUSION: Ten-group analysis showed that the 2006 cesarean rate increase was related to a significant shift in obstetric population toward groups 5 to 9 at higher risk of C-section, whereas after recommendation implementation a significant reduction of C-section subrates was observed in groups 1, 2a, 3, 4a, and 10 which represented more than 80% of the hospital population. In 2010, 10-group monitoring of the cesarean subrates stabilized the C-section rate. Ten-group analysis should be implemented in clinical practice to control delivery ward clinical management. It only requires the involvement of a clinical manager and of a midwife for data collection.

[125I]hGH metabolism in acromegaly: effects of chronic treatment with 2-Br-alpha-ergocryptine.

To assess the effects of 2-Br-alpha-ergocryptine (CB-154 Sandoz) on hGH metabolism, six acromegalic women were studied before and after 2 months of treatment with 10 mg bromocriptine/day. GH kinetics were evaluated by noncompartmental analysis of the plasma disappearance curve of immunoprecipitable [125I]human GH after pulse administration of the labeled hormone. MCR was increased in all acromegalics after treatment; the difference between the means [153 +/- 11 vs. 200 +/- 16 ml/min . m2 (mean +/- SE)] was highly significant. Secretion rate (SR), measured as the product of MCR by integrated 12-h concentration, was decreased in four patients after treatment, while it was slightly increased in the other two. No change was found after treatment, either initial distribution volume [2.0 +/-0.1 before (B) vs. 2.1 +/- 0.1 liters/m2 after (A)] or total distribution volume [5.0 +/- 0.3 (B) vs. 5.4 +/- 0.4 liters/m2 (A)]. Diffusion of GH from the intravascular pool, measured as reentry rate, was unchanged with treatment [66 +/- 4 (B) vs. 76 +/- 11 ml/min . m2 (A)]. In conclusion, our study shows that in acromegaly, by increasing the MCR of the hormone, and 2) by reducing the SR. The mechanisms by which bromocriptine increased MCR of the GH are also suggested on the basis of kinetic results; like dopamine, bromocriptine could induce a redistribution of blood flows to different organs, thus resulting in a net increase of blood flow to the liver and kidneys which are the major catabolic sites of GH.

Long-term survival following neoadjuvant chemotherapy and radical surgery in locally advanced cervical cancer.

The aim of this study was to analyse the long-term survival and the relationships between prognostic factors at presentation, chemoresponsiveness and disease outcome in patients with locally advanced cervical cancer treated by neoadjuvant chemotherapy and radical surgery (RS). Two consecutive studies of neoadjuvant chemotherapy containing cisplatin, bleomycin plus/minus methotrexate followed by radical hysterectomy and systematic aortic and pelvic lymphadenectomy were carried out between January 1986 and September 1990 on 130 patients with > or = 4 cm stage IB2-III cervical cancer. Survival analysis was performed using the Kaplan and Meier test and Cox's multivariate regression analysis. 128 (98%) of the patients enrolled were evaluable for clinical response and survival, 83% (106) of the patients responded to chemotherapy, with a 15% complete response rate. Logistic regression analysis demonstrated that International Federation of Gynecology and Obstetrics (FIGO) stage, cervical tumour size, parametrial involvement and histotype are highly predictive of response. Responding patients underwent laparotomy, but 8% were not amenable for radical surgery. The 10-year survival estimates were 91%, 80% and 34.5% for stage IB2-IIA bulky, IIB and III, respectively (P < 0.001). After Cox's regression analysis, the parameters significantly associated with survival were the same factors predicting response to neoadjuvant chemotherapy. No stage IB2-IIA bulky patient has so far relapsed, while 12% stage IIB and 56% stage III patients recurred. The 10-year disease-free survival estimates are 91% and 44% for stage IB2-IIB and III, respectively (P < 0.001). Metastatic nodes and persistent tumour in the parametria were the only two independent factors for disease-free survival after multiple regression analysis. After a long-term follow-up (median follow-up 98 months (20-129+)), our results give new evidence of the prognostic value of response to neoadjuvant chemotherapy and of a possible therapeutic benefit of the sequential treatment adopted which, however, must be verified in a randomised setting.

Insulin secretory response to oral glucose load, diabetic microangiopathy and diabetic control: a study in non-insulin dependent diabetics.

To study the importance of the residual insulin secretion for the degree of diabetic control and for the development of microangiopathy 55 patients with non-insulin-dependent diabetes mellitus (NIDDM) were studied. A 1 hr oral glucose tolerance test was performed at diagnosis and 5-10 yr later. At diagnosis all patients were free of microangiopathy, at reassessment 24 patients had evidence of microangiopathy, i.e. retinopathy, neuropathy or nephropathy, alone or in combination. The glucose induced increments of insulin levels (delta IRI) at reassessment correlated inversely with the degree of diabetic control, measured by Haemoglobin A1 (r = -0.466, p less than 0.01), and with the mean fasting blood glucose throughout the follow up period (r = -0.491, p less than 0.01). delta IRI at diagnosis was similar in patients with and without microangiopathy, and at reassessment, although lower in the microangiopathy group (11.2 +/- 2.1 vs. 16.4 +/- 2.1 microunits/ml, p less than 0.1). The difference between the 2 groups did not reach statistical significance. When patients were separated into those treated with diet alone and those treated with oral antidiabetic agents, delta IRI at reassessment was significantly lower in patients on oral agents (10.5 +/- 1.9 vs. 17.2 +/- 2.2 microunits ml, p less than 0.01), but the prevalence of microangiopathy was not different between 2 groups (37% and 52%, respectively). These findings show that in patients with NIDDM the residual beta cell function is important for the degree of diabetic control, but a direct relationship between the degree of insulin deficiency and the presence of diabetic microangiopathy is not established.

Twenty-four hour variations of von Willebrand factor and factor VIII-related antigen in diabetic retinopathy.

Factor VIII/von Willebrand factor (vWF) could play a role in the pathogenesis of diabetic microangiopathy. It has been suggested that its biologic activity is controlled by hormonal and metabolic mechanisms. To verify this hypothesis, vWF was monitored over a 24 hr period in 9 insulin treated patients with diabetic retinopathy, together with factor VIII-related antigen (VIII-RAG), plasma glucose, growth hormone (GH) and prolactin. vWF levels oscillated during the 24 hr, the mean values being higher during the day than at night-time, p less than 0.01. Compared to a group of normal controls in whom blood samples were taken randomly between 9.00 and 13.00, the levels of vWF were significantly increased at 11.00, p less than 0.02, and at 13.00, p less than 0.02, but at no other time. VIII-RAG values were also higher during the day than at night-time, p less than 0.01. The mean 24 hr levels of vWF correlated with those of VIII-RAG, p less than 0.01, with the age of the patients, p less than 0.01, and with the duration of disease, p less than 0.01. The levels of plasma glucose were higher during the day, while GH and prolactin rose at night-time. No correlations were found between vWF or VIII-RAG and plasma glucose, GH or prolactin, nor between the mean 24 hr levels of all these parameters and ponderal index, daily insulin dose, degree of metabolic control, severity of retinopathy. Insulin treated diabetics with microangiopathy show circadian variations in their plasma concentrations of vWF and VIII-RAG which should be taken into account when measuring these factors for clinical or research purposes.

Changes in plasma growth hormone in diabetic and nondiabetic subjects during the glucose clamp.

A group of 22 newly diagnosed noninsulin-dependent diabetic subjects and seven nondiabetic subjects underwent a glucose clamp at plasma glucose 100 mg/dL with insulin infusion rates of 1.0 and 10 mU/kg/min. During both insulin infusion rates, there was a sustained rise in plasma growth hormone (GH) above basal in 18 of the 22 diabetic subjects. Basal GH values were 2.37 +/- 0.67 ng/mL, rising above basal during the lower insulin infusion (6.1 +/- 3.3 ng/mL, P = 0.05) with a further rise at the higher insulin level (8.58 +/- 2.0 ng/mL, P less than 0.001). There was no rise in GH in any of the nondiabetic subjects. In neither group was there any rise above basal in cortisol, prolactin, glucagon, or somatostatin (SRIH). In a group of three nondiabetic subjects, a rise in GH similar to that seen in the diabetic group was induced by elevating the plasma glucose to 200 mg/dL for 60 minutes prior to the euglycemic clamp procedure. However, it is unlikely that changes in plasma glucose account totally for the changes in plasma GH described in the diabetic subjects since a rise in plasma GH was also seen in four diabetic subjects clamped at their fasting plasma glucose. We conclude that in newly diagnosed noninsulin-dependent diabetic subjects there is a rise in plasma GH during the euglycemic clamp procedure, which may be due to both the prior lowering of plasma glucose and the high plasma insulin levels.

A new transabdominal approach to the left retroperitoneum for systematic removal of lymph nodes left of the aorta in gynecologic malignancies.

To improve the exposure of the left retroperitoneum, a peritoneal incision is made in the left paracolic gutter up to the splenic flexure. By elevating and medially displacing the left colon, the avascular plane between this and the prerenal fascia is entered and developed caudally to the aorta bifurcation, and cranially 3-4 cm beyond the left renal pedicle. Thus, the left kidney, its pedicle, the ureter, the ovarian vessels, and the aorta are adequately exposed. In 81 patients with gynecologic tumors who underwent the modified lymphadenectomy, the median number of aortic nodes removed was 29 (range 21-56). The median duration of left dissection was 35 minutes (range 25-50) and of the entire aortic lymphadenectomy 70 minutes (range 50-120). No major intraoperative injuries occurred. The frequency and type of postoperative complications were not affected by this modification. This new approach provides better exposure of the left retroperitoneum, thus permitting safe and complete dissection of the nodes left of the aorta without increased morbidity. If aortic dissection can be limited to the left side, this technique makes it possible to avoid opening the right retroperitoneum.

Early feeding compared with nasogastric decompression after major oncologic gynecologic surgery: a randomized study.

OBJECTIVE: To evaluate the feasibility, safety, and tolerance of early feeding in patients undergoing surgery for gynecologic malignancies. METHODS: Patients were stratified according to operative time and type of tumor and were randomized into two arms: A) early oral feeding and B) nasogastric decompression followed by feeding at the first passage of flatus. Variables assessed included nausea, vomiting, time to first passage of flatus and stool, time elapsed before adequate tolerance of a regular diet, postoperative stay, and complications. RESULTS: Sixty-one patients were randomized into each arm. The types of tumor, the surgical procedures performed, and the operative times were similar in both groups. Early oral feeding in patients in arm A was associated with a significantly faster resolution of postoperative ileus (P < .01), with a more rapid return to a regular diet (P < .01), with an earlier first passage of stool (P < .01), and with a shorter postoperative stay (P < .05) than patients in arm B. Rates of nausea and vomiting were similar in both arms. Hindered deglutition and nasal soreness caused by the nasogastric tube were observed in 88% of patients in arm B. Insertion of a nasogastric tube was necessary in six patients in arm A (10%), and three of these had postoperative complications. Thus, early feeding was feasible in 95% of patients and did not seem to be related to preoperative chemotherapy, tumor type, or lymphadenectomy. CONCLUSION: Early feeding is feasible and well tolerated and is associated with reduced postoperative discomfort and a more rapid recovery in patients undergoing major surgery for gynecologic malignancies.

The pelvic retroperitoneal approach in the treatment of advanced ovarian carcinoma.

OBJECTIVE: To evaluate the feasibility, complications, and clinical role of pelvic cytoreduction using the retroperitoneal approach in the treatment of advanced ovarian cancer. METHODS: We studied 66 women with previously untreated advanced ovarian cancer who underwent pelvic retroperitoneal surgery. The possibility of achieving extrapelvic cytoreduction (residual disease less than 2 cm), involvement of the Douglas cul-de-sac or vesicouterine fold, or the presence of a frozen pelvis were indications for the retroperitoneal approach. Operative time, blood loss and transfusions, perioperative complications, and postoperative stay were analyzed prospectively. The performance status of each patient was assessed preoperatively and postoperatively. RESULTS: The pelvic retroperitoneal approach was used in 66 of 147 (45%) consecutive patients who underwent primary surgery with intent of cytoreduction. This approach was necessary in 60 of 94 (64%) patients with residual tumor less than 0.5 cm and contributed to achieving such a minimal residual disease in 36 of 38 (95%) stage IIB-IIIB and 58 of 109 (53%) IIIC-IV patients. Severe morbidity, but with no long-term sequelae, occurred in six (9%) patients. Before surgery, only ten (15%) of these patients had a performance status grade 0-1, 21 (32%) had grade 2, and 35 (53%) grade 3-4. After surgery, these figures were 52 (79%), 14 (21%), and 0, respectively. The 5-year survival rate was 37%, with a median survival and follow up time of 27 months (range 4-98) and 43 months, respectively. CONCLUSION: If the proper technique is used, complete pelvic cytoreduction is always feasible and morbidity is acceptable. In our series, it was necessary to approach the pelvis retroperitoneally in 64% of optimally cytoreduced patients, which suggests that this technique has an important clinical role in the treatment of patients with advanced ovarian cancer.