Bowel resection or repair at the time of cytoreductive surgery for ovarian malignancy is associated with increased complication rate: An ACS-NSQIP study.

OBJECTIVES: Bowel procedures are commonly performed as part of ovarian cancer cytoreduction. The aim of this study was to assess the postoperative complication rates among women with an ovarian malignancy undergoing bowel resection/repair at the time of cytoreductive surgery compared with a control group (cytoreductive surgery without bowel resection or repair). METHODS: Analysis of 4965 cytoreductive surgeries for suspected ovarian malignancies recorded in the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) datasets (2006-2017) was performed. One-way ANOVA, Kruskal-Wallis H and Chi-squared tests were used to evaluate and compare baseline characteristics between the groups and controls. Postoperative surgical site infection rates and other 30-day post-operative outcomes were assessed with multivariable logistic and linear regressions. RESULTS: 8.3% (413/4965) of cytoreductive procedures had an associated repair of enterotomy (small or large bowel), 10.9% (541/4947) had an associated colectomy with primary anastomosis, and 2.1% (104/4965) had an associated colectomy with colostomy. Surgical site infections (SSI, either superficial incisional, deep incisional, organ space or wound dehiscence) were significantly more prevalent in the bowel resection/repair group (16.9% vs 5.7%, p < 0.0001). The odds of surgical infections were 2.67 times higher in patients who underwent a bowel resection or repair after controlling for age, BMI, ASA status, pre-operative weight loss, hypoalbuminemia, NSQIP morbidity score, length and complexity of surgical procedure. CONCLUSION: Patients undergoing bowel resection/repair at the time of cytoreductive surgery are at increased risk of surgical site infections, without increased risk of 30-day mortality. Interventions to mitigate the risk of infectious complications in these patients should be evaluated in a prospective fashion.

Ecthyma Gangrenosum: Vulvar Ulcers, Pseudomonas, and Pancytopenia: A Case Report of an 18-Month-Old Female Toddler.

BACKGROUND: An 18-month-old female toddler presented with severe vulvar ulcers and pancytopenia with investigations revealing Pseudomonas aeruginosa bacteremia. CASE: A previously healthy 18-month-old female toddler presented with 6 days of fevers, vulvar rash, and ulcers. Vulvar cultures showed Staphylococcus aureus and P aeruginosa. Bloodwork showed pancytopenia and P aeruginosa bacteremia. She started receiving broad-spectrum antibiotics. Bone marrow aspirate revealed a hypocellular marrow with erythroid dysplasia. Vulvar ulcers progressed rapidly, therefore magnetic resonance imaging was performed to rule out necrotizing fasciitis. She was diagnosed with ecthyma gangrenosum (EG). Three months after initial presentation, she was diagnosed with precursor B-cell acute lymphoblastic leukemia. SUMMARY AND CONCLUSION: This case highlights that health care providers should suspect EG when severe vulvar ulcers are present with P aeruginosa infection and neutropenia. Because EG poses significant morbidity and mortality, its presence should prompt aggressive antimicrobial therapy and mobilization of a multidisciplinary team to initiate workup for an underlying immunodeficiency syndrome or malignancy. This case also illustrates that surgical debridement might be avoided in certain patients with EG as long as meticulous wound care and close monitoring with a multidisciplinary team are in place.

Incidence of Tissue Morcellation During Surgery for Uterine Sarcoma at a Canadian Academic Centre.

OBJECTIVES: To determine the incidence of tissue morcellation during surgery for uterine sarcoma in a Canadian tertiary academic centre. METHODS: In this retrospective cohort study, the clinical charts of all women who underwent hysterectomy for uterine sarcoma at the Ottawa Hospital between April 1, 2007, and March 31, 2014, were reviewed for their clinical characteristics and details of surgical treatment. RESULTS: Sixty-six cases of uterine sarcoma were identified. The mean (± SD) age of patients was 62.1 ± 10 years, and 81.8% were postmenopausal. Of the tumours, 43.9% were carcinosarcomas, 28.8% were leiomyosarcomas, 13.6% were endometrial stromal sarcomas, 6.1% were adenosarcomas, 1.5% were uterine rhabdomyosarcomas, and 6.1% were undifferentiated sarcomas. None of the surgical specimens were morcellated by laparoscopic power morcellation, and 61/66 (92.4%) of patients had their surgery performed by a gynaecologic oncologist. In the remaining five women whose surgery was performed by a general gynaecologist (4 with leiomyosarcomas and 1 with undifferentiated uterine sarcoma), two surgical specimens were morcellated manually using a scalpel during the removal of presumed fibroids at hysterectomy performed by midline laparotomy. The first of these was a case performed as an emergency because of acute pelvic symptoms secondary to leiomyosarcoma, and the second case had a solitary leiomyosarcoma among multiple benign leiomyomata. CONCLUSION: Uterine sarcomas are uncommon, and morcellation is rarely performed but may nevertheless be performed in the surgical management of presumed fibroids. Further studies and the establishment of a national registry are needed to better quantify the risk of morcellation, to characterize clinical risk factors, and to provide surgical alternatives for women undergoing uterine surgery.

Objectifs : Déterminer l'incidence du morcellement tissulaire dans le cadre des chirurgies visant des sarcomes utérins au sein d'un centre universitaire tertiaire canadien. Méthodes : Dans le cadre de cette étude de cohorte rétrospective, les dossiers cliniques de toutes les femmes qui ont subi une hystérectomie en raison d'un sarcome utérin à L'Hôpital d'Ottawa, entre le 1er avril 2007 et le 31 mars 2014, ont été analysés en vue d'en tirer les caractéristiques cliniques et d'établir les détails du traitement chirurgical mis en œuvre. Résultats : Soixante-six cas de sarcome utérin ont été identifiés. L'âge moyen (± σ) des patientes était de 62,1 ± 10 ans et 81,8 % d'entre elles étaient postménopausées. Les tumeurs se répartissaient comme suit : 43,9 % d'entre elles étaient de carcinosarcomes; 28,8 %, des léiomyosarcomes; 13,6 %, des sarcomes du chorion cytogène; 6,1 %, des adénosarcomes; 1,5 %, des rhabdomyosarcomes utérins; et 6,1 %, des sarcomes indifférenciés. Aucun des prélèvements chirurgicaux n'a été soumis à un morcellement motorisé laparoscopique et, chez 61/66 (92,4 %) des patientes, la chirurgie a été menée par un gynéco-oncologue. Chez les cinq autres femmes (léiomyosarcomes dans quatre de ces cas et sarcome utérin indifférencié dans l'autre), pour lesquelles la chirurgie a été menée par un gynécologue généraliste, deux prélèvements chirurgicaux ont été morcelés de façon manuelle au moyen d'un scalpel pendant le retrait de fibromes présumés au moment d'une hystérectomie menée par laparotomie médiane. Dans le premier de ces deux cas, l'intervention a été menée d'urgence en raison de la présence de symptômes pelviens aigus attribuables à un léiomyosarcome, tandis que dans l'autre, la patiente en question présentait un léiomyosarcome solitaire situé parmi de multiples léiomyomes bénins. Conclusion : Les sarcomes utérins sont peu courants; de plus, bien qu'un morcellement soit rarement mis en œuvre, une telle intervention peut néanmoins en venir à être menée dans le cadre de la prise en charge chirurgicale de fibromes présumés. La tenue d'autres études et l'établissement d'un registre national s'avèrent requis pour mieux quantifier le risque lié au morcellement, pour définir les facteurs de risque cliniques et pour fournir des solutions de rechange chirurgicales aux femmes qui doivent subir une chirurgie utérine.