Intestinal Surgery in Gynecologic Oncology: Are We Training for the Future?

OBJECTIVE: The objective of this study was to assess the scope of intestinal surgery training across gynecologic oncology fellowships in the United States and identify factors associated with perceived preparedness to perform intestinal surgery independently. MATERIALS/METHODS: An institutional review board-approved survey was distributed to Society of Gynecologic Oncology fellows and candidate members within the first 3 years of practice. Questions addressed demographics, operative experience, preparedness and plans for performing intestinal surgery, and attitudes toward gynecologic oncologists (GOs) performing intestinal surgery. Responses were analyzed using descriptive statistics as well as univariate and multivariate analyses. RESULTS: Of 374 Society of Gynecologic Oncology members invited, 108 (29%) responded, including 38 fellows (35%) and 53 recent graduates (49%). Fifteen (14%) reported more than 3 years of practice and were excluded. Most participants (96%) received intestinal surgery training from GOs, and 64% reported that all faculty routinely performed intestinal surgery. Most participants (81%) believed GOs should perform intestinal procedures, whereas only 58% felt prepared and 59% planned to perform intestinal procedures independently. Fellows who performed more than 10 intestinal diversion procedures, participated directed in intestine-related intraoperative consultations, or reported that all faculty performed intestinal surgery were more likely to feel prepared to perform intestinal surgery independently. Sex, training region, intended practice environment, and fellowship curriculum were not associated with preparedness to perform intestinal surgery. CONCLUSIONS: Almost half of gynecologic oncology fellows and recent graduates in the United States do not feel prepared to perform intestinal procedures independently after fellowship. Increased volume and direct involvement of fellows in intestinal surgery may improve preparedness for performing intestinal surgery after fellowship.

Compliance with research standards within gynecologic oncology fellowship: A Gynecologic Oncology Fellowship Research Network (GOFRN) study.

OBJECTIVES: Participation in clinical and basic science research is emphasized in gynecologic oncology training. We sought to identify trends in adherence to expected research practices and reasons for non-adherence among gynecologic oncology fellows. METHODS: An anonymous 31-question online survey assessing academic behaviors, including IRB compliance, authorship assignment, data sharing, and potential barriers to non-adherence was distributed to all SGO gynecologic oncology fellow members in July 2016. Descriptive statistics and univariate analyses were performed. RESULTS: Of 190 members, 35.3% (n=67) responded. 73% (n=49) of respondents reported personal non-compliance and 79.1% (n=53) reported having witnessed others being non-complaint with at least one expected research practice. Areas of compliance failure included changing a research question without appropriate IRB amendment (20%; n=14), conducting research under a nonspecific IRB (13.9%; n=9), and performing research without IRB approval (6.1%; n=4). Longer institutional time for IRB approval was significantly associated with IRB non-adherence (p<0.05). First year fellows were more likely to use a nonspecific IRB (p=0.04) or expand a question without amending the IRB (p=0.04). When asked about storage of protected health information (PHI) for research, 53% reported non-secure storage with 17.1% (n=6) having done so for >1000 patients. Thirty respondents (45.5%) assigned authorship to someone who failed to meet ICMJE criteria and twelve (18.5%) accepted authorship without meeting ICMJE criteria. Most commonly cited reasons for non-adherence were: cumbersome IRB processes (80.3%), pressure from senior authors (78.8%), fear of someone else publishing first, (74.2%) and lack of support navigating appropriate research practices (71.2%). CONCLUSIONS: Fellow non-compliance with expected research practices is high, particularly with regards to secure storage of PHI and appropriate authorship assignment. Time-consuming and cumbersome IRB procedures, perceived pressure from senior authors, and lack of research support contribute to non-adherence. Further support and education of gynecologic oncology fellows is needed in order to help address these barriers.

Postoperative Outcomes after Single-port Laparoscopic Removal of Adnexal Masses in Patients Referred to Gynecologic Oncology at a Large Academic Center.

STUDY OBJECTIVE: To report surgical and pathologic outcomes after single-port laparoscopy (SPL) for adnexal masses in patients referred to a gynecologic oncology practice at a single academic institution. DESIGN: A retrospective analysis (Canadian Task Force Classification II.2). SETTING: A single academic institution with multiple hospital centers. PATIENTS: Women who underwent at least 1 single-port laparoscopic surgery for the treatment of an adnexal mass from 2009 to 2015 after referral to a gynecologic oncology practice. INTERVENTION: Data were collected on the surgical procedure, patient demographic variables, 30-day surgical outcomes, and hernia development. MEASUREMENTS AND MAIN RESULTS: Three hundred twenty-five surgeries were performed in 322 patients with a median follow-up of 42.7 months. The median age was 54.5 years, and the median body mass index was 28.1 kg/m2. All patients underwent unilateral or bilateral salpingectomy or oophorectomy with or without hysterectomy (26.5%). The median operative time was 90.0 minutes. The median mass dimension was 6.4 cm with 17.9% (n = 60) greater than 10 cm. Masses were categorized as simple (11.4%) and complex (69.5%). Although the majority (87.4%) of masses were benign, 7.4% were malignant, and 5.2% were borderline. Benign masses were physiologic (16.6%), serous cystadenomas (19.1%), mucinous cystadenomas (6.8%), endometriomas (12.3%), myomas (12.3%), and mature teratomas (9.2%). In malignant cases (7.4%), serous carcinoma was the most frequent histology (58.3%). The rate of adverse outcomes within 30 days, including reoperation (0.0%), intraoperative injury (1.5%), venous thromboembolism (0.3%), and transfusion (0.6%), was low. The development of incisional cellulitis was 4.6%. The rate of incisional hernia was 4.0%, with a median occurrence of 18.3 months. Diabetes mellitus (p = .03) and obesity (p = .04) were significant predictors for a hernia, but mass complexity (p = .28), American Society of Anesthesiologists class (p = .83), and smoking (p = .82) were not. CONCLUSION: In patients undergoing SPL for the removal of adnexal masses in a gynecologic oncology practice, the rate of benign disease is high. SPL removal of adnexal masses is feasible and safe with favorable surgical outcomes, rare short-term adverse outcomes, and a low incisional hernia rate.

Pelvic surgical site infections in gynecologic surgery.

The development of surgical site infection (SSI) remains the most common complication of gynecologic surgical procedures and results in significant patient morbidity. Gynecologic procedures pose a unique challenge in that potential pathogenic microorganisms from the skin or vagina and endocervix may migrate to operative sites and can result in vaginal cuff cellulitis, pelvic cellulitis, and pelvic abscesses. Multiple host and surgical risk factors have been identified as risks that increase infectious sequelae after pelvic surgery. This paper will review these risk factors as many are modifiable and care should be taken to address such factors in order to decrease the chance of infection. We will also review the definitions, microbiology, pathogenesis, diagnosis, and management of pelvic SSIs after gynecologic surgery.

Endomyometritis after cesarean delivery in the era of antibiotic prophylaxis: incidence and risk factors.

PURPOSE: To identify the rate of postpartum endomyometritis (PPE) after cesarean delivery (CD) in the era of antibiotic prophylaxis and determine risk factors. METHODS: A single institution retrospective study was performed in women undergoing CD. Data regarding obstetrical and surgical variables were collected. Diagnosis of PPE was made clinically. RESULTS: Among 2419 patients, the rate of PPE was 1.6% (n = 38) and was associated with lower age (27.0 versus 31.0; p < .001). 65.7% of patients having chorioamnionitits developed PPE, but only 5.4% of patients without PPE had chorioamnionitis (p < .001). On multivariate analysis, PPE was higher in emergent versus scheduled CD (OR: 5.89; p = .0081). There was no difference in PPE for cefazolin 2 g versus 1 g (OR: 1.91; p = .17) or 3 g versus 1 g (OR: 3.69; p = .29), gentamicin/clindamycin versus cefazolin (OR: 5.60; p < .001) had higher PPE. Women with PPE were more likely to have labor arrest (OR: 4.336; p = .001), sexually transmitted infection during the pregnancy (OR: 4.197; p = .02) or blood transfusion (OR: 9.50; p < .0001). CONCLUSIONS: While the overall rate of PPE was low, several risk factors were identified. Preoperative diagnosis of chorioamnionitits is associated with a higher rate of PPE. Further studies are needed to identify optimal regimens for antimicrobial prophylaxis in women undergoing CD.

A model to predict risk of postpartum infection after Caesarean delivery.

PURPOSE: The purpose of this study is to build and validate a statistical model to predict infection after caesarean delivery (CD). METHODS: Patient and surgical variables within 30 d of CD were collected on 2419 women. Postpartum infection included surgical site infection, urinary tract infection, endomyometritis and pneumonia. The data were split into model development and internal validation (1 January-31 August; N = 1641) and temporal validation subsets (1 September-31 December; N = 778). Logistic regression models were fit to the data with concordance index and calibration curves used to assess accuracy. Internal validation was performed with bootstrapping correcting for bias. RESULTS: Postoperative infection occurred in 8% (95% CI 7.3-9.9), with 5% meeting CDC criteria for surgical site infections (SSI) (95% CI 4.1-5.8). Eight variables were predictive for infection: increasing BMI, higher number of prior Caesarean deliveries, emergent Caesarean delivery, Caesarean for failure to progress, skin closure using stainless steel staples, chorioamnionitis, maternal asthma and lower gestational age. The model discriminated between women with and without infection on internal validation (concordance index = 0.71 95% CI 0.67-0.76) and temporal validation (concordance index = 0.70, 95% CI 0.62, 0.78). CONCLUSIONS: Our model accurately predicts risk of infection after CD. Identification of patients at risk for postoperative infection allows for individualized patient care and counseling.

Surgical site infection after cesarean delivery: incidence and risk factors at a US academic institution.

PURPOSE: To identify the rate of surgical site infection (SSI) after Cesarean delivery (CD) and determine risk factors predictive for infection at a large academic institution. METHODS: This was a retrospective cohort study in women undergoing CD during 2013. SSIs were defined by Centers for Disease Control (CDC) criteria. Chi square and t-tests were used for bivariate analysis and multivariate logistic regression was used to identify SSI risk factors. RESULTS: In 2419 patients, the rate of SSI was 5.5% (n = 133) with cellulitis in 4.9% (n = 118), deep incisional infection in 0.6% (n = 15) and intra-abdominal infection in 0.3% (n = 7). On multivariate analysis, SSI was higher among CD for labor arrest (OR 2.4; 95%CI 1.6-3.5; p <.001). Preterm labor (OR 2.8; 95%CI 1.3-6.0; p = .01) and general anesthesia (OR 4.4; 95%CI 2.0-9.8; p = .003) were predictive for SSI. Increasing BMI (OR 1.1; 95%CI 1.05-1.09; p = .02), asthma (OR 1.9; 95%CI 1.1-3.2; p = .02) and smoking (OR 1.9; 95%CI 1.1-3.2; p = .02) were associated with increased SSI. CONCLUSIONS: Several patient and surgical variables are associated with increased rate of SSI after CD. Identification of risk factors for SSI after CD is important for targeted implementation of quality improvement measures and infection control interventions.

Management of Retained Genital Piercings: A Case Report and Review.

The prevalence of genital piercing among women is increasing. As the popularity increases, the number of complications from infection, injury, and retained jewelry is likely to rise. Techniques to remove embedded jewelry are not well described in the literature. The purpose of this report was to describe a case of a patient with a retained clitoral glans piercing, discuss a simple technique for outpatient removal, and review current evidence regarding associated risks of clitoral piercings. A 24-year-old female presented to the emergency department with an embedded clitoral glans piercing. Local anesthetic was injected into the periclitoral skin and a small superficial vertical incision was made to remove the ball of the retained barbell safely. In conclusion, among patients with retained genital piercing, outpatient removal of embedded jewelry is feasible. While the practice of female genital piercing is not regulated, piercing of the glans of the clitoris is associated with increased injury to the nerves and blood supply of the clitoris structures leading to future fibrosis and diminished function compared to piercing of the clitoral hood.

Adverse post-operative outcomes in Jehovah's witnesses with gynecologic cancer within 30 days of surgery: A single institution review of 36 cases.

Rates of blood transfusion are reported as high as 32% in women undergoing major gynecologic cancer surgery. Therefore, care of the gynecologic oncology patient who refuses blood products, such as Jehovah's witnesses, can pose a unique challenge. The objective of this study was to determine rate of adverse post-operative outcomes within 30 days of surgery in Jehovah's witnesses with gynecologic cancer. This was a retrospective cohort study of Jehovah's witnesses undergoing laparotomy or minimally invasive surgery (MIS) for gynecologic cancer at a single institution. Data for post-adverse complications within 30 days of surgery were recorded. In total, 36 patients were included with a median age of 58.5 years (32-85 years). The majority had endometrial adenocarcinoma (n = 23; 63.9%) or epithelial ovarian, fallopian tube or peritoneal cancer (EOC) (n = 8; 22.2%). 61.1% (n = 22) of patients underwent laparotomy and 38.9% (n = 14) had MIS procedures. 31.8% of laparotomies (n = 7) were terminated prematurely due to surgeon concern for ongoing blood loss. In patients with advanced stage EOC, the rate of suboptimal cytoreduction (> 1 cm) was 50%. In the laparotomy cohort, there were four (18.2%) ICU admissions and two (9.1%) mortalities. The time to adjuvant chemotherapy or radiation was 45.5 days (31-64) for laparotomy compared to 35.0 days (12-64) for MIS. While the majority of patients (97.2%) were unwilling to accept packed red blood cells, over one third (38.9%) were agreeable to autologous blood transfusion. Additionally, five (13.9%) patients were accepting of fresh frozen plasma, six (16.7%) patients were agreeable to cryoprecipitate and seven (19.4%) patients were willing to accept platelet transfusions. There is a high rate of postoperative adverse outcomes among Jehovah's witnesses undergoing laparotomy for gynecologic malignancy compared. Acceptance of blood products is low among Jehovah's witnesses, even in the setting of major oncologic surgery.

Infection Prevention and Evaluation of Fever After Laparoscopic Hysterectomy.

BACKGROUND: Surgical site infection (SSI) is a common complication of hysterectomy. Minimally invasive hysterectomy has lower infection rates than abdominal hysterectomy. The lower SSI rates reflect the role and benefit in infection control of having minimal incisions, rather than a large anterior abdominal wall incision. Despite the lower rates, SSI after laparoscopic hysterectomy is not uncommon.In this article, we review pre-, intra-, and postoperative risk factors for infection. Rates of postoperative fever after laparoscopic hysterectomy and when evaluation for infection is warranted in a febrile patient are also reviewed. DATABASE: PubMed was searched for English-only articles using National Library of Medicine Medical Subject Headings(MESH) terms and keywords including but not limited to "postoperative," "surgical site," "infection," "fever," "laparoscopic," "laparoscopy," and "hysterectomy." CONCLUSIONS: Reducing hospital-acquired infections such as SSI is one of the more effective ways of improving patient safety. Knowledge and understanding of risk factors for infection following laparoscopic hysterectomy enable the gynecologic surgeon or hospital to implement targeted preventive measures.