What Should a Gynecologist Know about Li-Fraumeni Syndrome? Lessons from a Patient Undergoing Hysterectomy for Benign Indications.

Li-Fraumeni syndrome (LFS) is a rare highly penetrant cancer syndrome characterized by mutation in the TP53 tumor suppressor gene. Recent data suggest that this germline mutation is more frequent than once thought. While LFS has not been associated previously with pelvic serous carcinoma, gynecologic malignancies have been reported in this patient population. We present the case report of a 37-year-old patient with known LFS and a history of multiple cancers who underwent total abdominal hysterectomy for benign indications with incidental bilateral salpingo-oophorectomy. On final pathology, she was found to have serous tubal intraepithelial carcinoma of bilateral fallopian tubes. Our findings raise the question of the potential role of prophylactic gynecologic cancer-reducing surgery in this patient population.

Margins for cervical and vulvar cancer.

Surgery is the primary treatment for vulvar cancer as well as early-stage carcinoma of the cervix. This article reviews the significance of margin status after surgery on overall survival, need for further surgical intervention, and role for possible adjuvant therapy. It summarizes the abundant literature on margin status in vulvar cancer and highlights the need for further investigation on the prognostic significance of margins in cervical cancer. In addition, it reviews other important operative considerations.

Simple Technique for Transvaginal Aspiration of a Tubo-Ovarian Abscess.

Large tubo-ovarian abscesses (TOAs) usually require drainage or operative management in addition to antibiotics. All previous reports of transvaginal aspiration have been described utilizing a needle/biopsy guidance system, which may not be available to many obstetrician/gynecologists. We present a simple technique for transvaginal drainage of large TOAs using a long angiocath needle under transabdominal ultrasound guidance in a patient in whom percutaneous drainage and operative management were not ideal options. This is the first report about the use of this technique. Our patient has recovered fully and remains free of infection 10 months later. Providers should consider this technique when other modalities are not available, are of questionable benefit, or present high potential for additional complications.

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.

Prevalence of occult gynecologic malignancy at the time of risk reducing and nonprophylactic surgery in patients with Lynch syndrome.

OBJECTIVE: The primary aim of this study was to determine the prevalence of occult gynecologic malignancy at the time of risk reducing surgery in patients with Lynch Syndrome. A secondary aim was to determine the prevalence of occult gynecologic malignancy at the time of surgery for non-prophylactic indications in patients with Lynch Syndrome. METHODS: A retrospective review of an Inherited Colorectal Cancer Registry found 76 patients with Lynch syndrome (defined by a germline mutation in a DNA mismatch repair gene) or hereditary nonpolyposis colorectal cancer (HNPCC) (defined by Amsterdam criteria) who had undergone hysterectomy and/or salpingo-oophorectomy for a prophylactic or non-prophylactic indication. Indications for surgery and the prevalence of cancer at the time of each operation were reviewed. RESULTS: 24 of 76 patients underwent prophylactic hysterectomy and/or bilateral salpingo-oophorectomy for Lynch syndrome or HNPCC. In 9 of these patients, a benign indication for surgery was also noted. 4 of 24 patients (17%, 95% CI = 5-38%) were noted to have cancer on final pathology. 20 of 76 patients (26%) undergoing operative management for any indication were noted to have occult malignancy on final pathology. CONCLUSIONS: Patients should be counseled about the risks of finding gynecologic cancer at the time of prophylactic or non-prophylactic surgery for Lynch syndrome and HNPCC, and the potential need for additional surgery.

Beta-blocker prophylaxis for total knee arthroplasty patients: a case series.

Cardiac complications are an infrequent yet undesirable cause of morbidity and mortality following total knee arthroplasty. Perioperative prophylaxis with beta-blocker medication has been shown to reduce in-hospital cardiac deaths in noncardiac surgical patients. This study evaluated the safety and in-hospital cardiac complications of a consecutive cohort of 267 total knee arthroplasties in patients who followed a perioperative beta-blocker prophylaxis institutional protocol. The patients were categorized into three groups: A, already on a beta-blocker; B, beta-blocker prescribed by orthopaedic surgeon; and C, not given the medication. The 90-day mortality and in-hospital cardiac complications were evaluated. Of the patients who had 267 procedures, 203 (76%) received beta-blocker prophylaxis perioperatively: 110 (41.2%) were already on the medication preoperatively, 93 (34.8%) were prescribed the medication by the surgeon, and 64 (24%) did not receive this medication. There were no deaths within the first 90 days. There were two nonfatal myocardial infarctions (0.7%) and six other cardiac complications (2.2%). With a beta-blocker prophylaxis protocol implemented by one surgeon, 76% of total knee arthroplasty patients were given the medication and it was prescribed in 34.8% by the orthopaedic surgeon. In-hospital cardiac complications were low.

Are the relative indications for revision total knee arthroplasty changing?

There are relatively few data on the indications for revision total knee arthroplasty. The purpose of this study was to determine if the indications for revision have changed over the past decade. This is a retrospective review of demographic data and the indications for revision in two cohorts of patients by one surgeon. Patient gender, age, weight, time in situ, and reason for revision (eight categories) were recorded and analyzed by unpaired t-tests and chi-square tests. The first cohort was 81 revisions performed between 1990 and 1999. The second cohort was 116 revisions performed between 2000 and April 2008. There were no significant differences in the gender, mean age, mean weight, or mean time in situ between the two cohorts. There were more revisions for wear (p = .03) and instability (p = .06) in the recent cohort. There were significantly fewer revisions related to the patella prosthesis (p < .0001). There was no change in the number of revisions for infection between the two cohorts. The relative indications for revision total knee arthroplasty have changed over the past decade. Greater emphasis may be needed on improved balancing techniques to prevent instability and new bearing surfaces to decrease wear.

Ovarian carcinoma initially presenting as breast cancer two years prior to diagnosis: A case report and review of literature.

•Ovarian cancer presenting as a primary breast cancer two years prior•Ovarian cancer with metastases to breast is rare.•Metastases to the breast generally present as a recurrence.•Delay in diagnosis likely due to chemotherapy given for breast disease.

Risk factors for robotic gynecologic procedures requiring conversion to other surgical procedures.

OBJECTIVE: To determine the incidence of, and risk factors for, conversion from robotic gynecologic procedures to other procedure types. METHODS: A retrospective cohort study included data from women who underwent any robotic gynecologic procedures between January 1, 2011 and December 31, 2012 at a tertiary care referral center in the USA. Demographic data, perioperative data, and surgeon experience (monthly case volume) data were retrieved; potential risk factors were compared between robotic procedures that were converted to other procedures and those completed as robotic procedures. RESULTS: There were 942 robotic procedures during the study period. Conversion from robotic to any other type of procedure was recorded for 47 (5.0%, 95% confidence interval 3.8-6.6) procedures and robotic-to-open-surgery conversion occurred in 16 (1.7%, 95% confidence interval 1.0-2.7) procedures. Conversion from robotic surgery to another approach was associated with higher body mass index (P<0.001), previous laparotomy (P=0.042), and surgeons having a lower monthly robotic surgical case volume (P=0.011). Asthma (P=0.008), intra-operative bowel injury (P<0.001), intra-operative vascular injury (P=0.003), and single-port robotic surgery (P=0.034) were associated with increased odds of requiring conversion from robotic procedures. CONCLUSION: The overall incidence of conversion from robotic surgery to laparotomy was low. Higher body mass index, previous laparotomy, history of asthma, using a single-port approach, and surgeon case volume were associated with the risk of conversion.

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.