Impact of ERAS in breast reconstruction with a latissimus dorsi flap, compared to conventional management.

BACKGROUND: Enhanced recovery after surgery (ERAS) programs are associated with improved management, reduced hospital stays, and lower complication rates. OBJECTIVE: To evaluate the impact of ERAS on mean length of stay (LOS) and postoperative morbidity in breast reconstruction with latissimus dorsi flap (LDF) compared with conventional recovery program. PATIENTS AND METHOD: All patients operated by LDF between December 2014 and October 2020: those managed before April 2018, when the ERAS protocol was introduced, were included in the "no ERAS" group, and beyond in the "ERAS" group. RESULTS: Out of 193 patients, 129 were included in the "ERAS" group and 64 in the "no ERAS" group. There was a significant difference between the two groups in LOS (4.2 ± 1.5 days in the "ERAS" group vs. 5.4 ± 1.9 days in the "no ERAS" group; p < 0.001), high-grade complications at 30 days (9.3% in the "ERAS" group vs. 25% in the "no ERAS" group; p = 0.01), reintervention rate (13.9% vs. 26.6%, respectively; p = 0.02), and 30-day rehospitalization rate (6.2% in the "ERAS" group vs. 15.6% in the "no ERAS" group; p = 0.03). CONCLUSION: The ERAS protocol has a positive impact on breast reconstruction with LDF without generating additional adverse effects. These results support the democratization of these programs for breast reconstruction surgery.

Borderline ovarian tumors: Guidelines from the French national college of obstetricians and gynecologists (CNGOF).

It is recommended to classify Borderline Ovarian Tumors (BOTs) according to the WHO classification. Transvaginal and suprapubic ultrasonography are recommended for the analysis of an ovarian mass (Grade A). In case of an undetermined ovarian lesion on ultrasonography, it is recommended to perform a pelvic MRI (Grade A) with a score for malignancy (ADNEX MR/O-RADS) (Grade C) included in the report and to formulate a histological hypothesis (Grade C). Pelvic MRI is recommended to characterize a tumor suspected of being BOT (Grade C). It is recommended to evaluate serum levels of HE4 and CA125 and to use the ROMA score for the diagnosis of indeterminate ovarian mass on imaging (grade A). If there is a suspicion of a mucinous BOT on imaging, serum levels of CA 19-9 may be proposed (Grade C). For Early Stages (ES) of BOT, if surgery without risk of tumor rupture is possible, laparoscopy with protected extraction is recommended over laparotomy (Grade C). For treatment of a bilateral serous ES BOT with a strategy to preserve fertility and/or endocrine function, bilateral cystectomy is recommended where possible (Grade B). For mucinous BOTs with a treatment strategy of fertility and/or endocrine function preservation, unilateral salpingo-oophorectomy is recommended (grade C). For mucinous BOTs treated by initial cystectomy, unilateral salpingo-oophorectomy is recommended (grade C). For serous or mucinous ES BOTs, routine hysterectomy is not recommended (Grade C). For ES BOTs, lymphadenectomy is not recommended (Grade C). For ES BOTs, appendectomy is recommended only in case of a macroscopically pathological appendix (Grade C). Restaging surgery is recommended in cases of serous BOTs with micropapillary architecture and an incomplete abdominal cavity inspection during initial surgery (Grade C). Restaging surgery is recommended for mucinous BOTs after initial cystectomy or in cases where the appendix was not examined (Grade C). If restaging surgery is decided for ES BOTs, the following procedures should be performed: peritoneal washing (grade C), omentectomy (grade B), complete exploration of the abdominal cavity with peritoneal biopsies (grade C), visualization of the appendix and appendectomy in case of a pathological macroscopic appearance (grade C) as well as unilateral salpingo-oophorectomy in case of a mucinous BOT initially treated by cystectomy (grade C). In advanced stages (AS) of BOT, it is not recommended to perform a lymphadenectomy as a routine procedure (Grade C). For AS BOT in a patient with a desire to fall pregnant, conservative treatment involving preservation of the uterus and all or part of the ovary may be proposed (Grade C). Restaging surgery aimed at removing all lesions, not performed initially, is recommended for AS BOTs (Grade C). After treatment, follow-up for a duration greater than 5 years is recommended due to the median recurrence time of BOTs (Grade B). It is recommended that a systematic clinical examination be carried out during follow-up of a treated BOT (Grade B). If the determination of tumor markers is normal preoperatively, the routine dosage of tumor markers in BOT follow-up is not recommended (Grade C). In case of an initial elevation in serum CA 125 levels, it is recommended to monitor CA 125 during follow up (Grade B). In case of conservative treatment, it is recommended to use transvaginal and transabdominal ultrasound during follow up of a treated BOT (Grade B). In the event of a BOT recurrence in a woman of childbearing age, a second conservative treatment may be proposed (Grade C). A consultation with a physician specialized in Assisted Reproductive Technique (ART) should be offered in the case of BOTs in women of childbearing age (Grade C). When possible, a conservative surgical strategy is recommended to preserve fertility in women of childbearing age (Grade C). In the case of optimally treated BOT, there is no evidence to contraindicate the use of ART. The use of hormonal contraception after serous or mucinous BOT is not contraindicated (Grade C). After management of mucinous BOT, for women under 45 years, given the benefit of Hormonal Replacement Therapy (HRT) on cardiovascular and bone risks, and the lack of hormone sensitivity of mucinous BOTs, it is recommended to offer HRT (Grade C). Over 45 years of age, HRT can be prescribed in case of a climacteric syndrome after individual benefit to risk assessment (Grade C).

[Borderline Ovarian Tumours: CNGOF Guidelines for Clinical Practice - Diagnosis and Management of Recurrent Borderline Ovarian Tumours]. / Tumeurs frontières de l'ovaire. Recommandations pour la pratique clinique du CNGOF ­ Diagnostic et prise en charge des récidives.

OBJECTIVE: To provide recommendations for the diagnosis and management of the recurrence of Borderline Ovarian Tumour (BOT). METHODS: Literature review by consulting Pubmed, Medline and Cochrane databases. RESULTS: In the case of BOT, most of recurrences are a new BOT without invasive contingent (LE2). In the case of bilateral BOT, bilateral cystectomy is associated with a shorter recurrence time compared to unilateral oophorectomy and contralateral cystectomy (LE2). In recurrent serous BOT, cysts are usually fluid thin-walled with vegetation, corresponding in the IOTA classification to a solid unilocular cyst (LE2). A size of the cyst less than 20mm is not a sufficient to eliminate the diagnosis of recurrent serous BOT (LE2). Recurrence of mucinous BOT predominantly appears as multilocular or as solid multilocular cysts (LE4). In the case of ovarian preservation, recurrences are most often observed on the preserved ovary(s) (LE2). Non-invasive peritoneal recurrence after initial radical treatment including bilateral hysterectomy and adnexectomy is possible, mainly in patients initially diagnosed with stage II or III BOT with non-invasive peritoneal implant (LE3). Most BOT recurrences are asymptomatic, but clinical examination may allow diagnosis of recurrence (LE2). The normality of the CA 125 dosage does not rule out the diagnosis of recurrent BOT (LE2). A second conservative treatment in the event of recurrence of BOT entails the risk of new recurrence (LE2) with no impact on survival (LE4). Totalization of the adnexectomy in case of recurrence of BOT reduces the risk of new recurrence (LE2). Conservative treatment does not increase the risk of recurrence with non-invasive peritoneal implants (LE4). Conservative treatment may be offered after a first non-invasive recurrence in young women who wish to preserve their fertility (gradeC). In the absence of infiltrating tumor, chemotherapy is not indicated. The only cases for which chemotherapy can be considered are those for which there is an infiltrative component in addition to TFO.

[Borderline Ovarian Tumours: CNGOF Guidelines for Clinical Practice - Epidemiology and Risk Factors of Relapse, Follow-up and Interest of a Completion Surgery]. / Tumeurs frontières de l'ovaire. Recommandations pour la pratique clinique du CNGOF ­ Épidémiologie et facteurs de risques de récidive, modalités de surveillance et intérêt d'une chirurgie de clôture.

OBJECTIVE: To provide clinical practice guidelines from the French college of obstetrics and gynecology (CNGOF) based on the best evidence available, concerning epidemiology of recurrence, the risk or relapse and the follow-up in case of borderline ovarian tumor after primary management, and evaluation of completion surgery after fertility sparing surgery. MATERIAL AND METHODS: English and French review of literature from 2000 to 2019 based on publications from PubMed, Medline, Cochrane, with keywords borderline ovarian tumor, low malignant potential, recurrence, relapse, follow-up, completion surgery. From 2000 up to this day, 448 references have been found, from which only 175 were screened for this work. RESULTS AND CONCLUSION: Overall risk of recurrence with Borderline Ovarian Tumour (BOT) may vary from 2 to 24% with a 10-years overall survival>94% and risk of invasive recurrence between 0.5 to 3.8%. Age<40 years (level of evidence 3), advanced initial FIGO stage (LE3), fertility sparing surgery (LE2), residual disease after initial surgery for serous BOT (LE2), implants (invasive or not) (LE2) are risk factors of recurrence. In case of conservative treatment, serous BOT had a higher risk of relapse than mucinous BOT (LE2). Lymphatic involvement (LE3) and use of mini invasive surgery (LE2) are not associated with a higher risk of recurrence. Scores or Nomograms could be useful to assess the risk of recurrence and then to inform patients about this risk (gradeC). In case of serous BOT, completion surgery is not recommended, after conservative treatment and fulfillment of parental project (grade B). It isn't possible to suggest a recommendation about completion surgery for mucinous BOT. There is not any data to advise a frequency of follow-up and use of paraclinic tools in general case of BOT. Follow-up of treated BOT must be achieved beyond 5 years (grade B). A systematic clinical examination is recommended during follow-up (grade B), after treatment of BOT. In case of elevation of CA-125 at diagnosis use of CA-125 serum level is recommended during follow-up of treated BOT (grade B). When a conservative treatment (preservation of ovarian pieces and uterus) of BOT is performed, endovaginal and transabdominal ultrasonography is recommended during follow-up (grade B). There isn't any sufficient data to advise a frequency of these examinations (clinical examination, ultrasound and CA-125) in case of treated BOT. CONCLUSION: Risk of relapse after surgical treatment of BOT depends on patients' characteristics, type of BOT (histological features) and modalities of initial treatment. Scores and nomogram are useful tools to assess risk of relapse. Follow-up must be performed beyond 5 years and in case of peculiar situations, use of paraclinic evaluations is recommended.

[Borderline Ovarian Tumours: CNGOF Guidelines for Clinical Practice - Short Text]. / Tumeurs frontières de l'ovaire. Recommandations pour la pratique clinique du CNGOF ­ Texte court.

This work was carried out under the aegis of the CNGOF (Collège national des gynécologues et obstétriciens français) and proposes guidelines based on the evidence available in the literature. The objective was to define the diagnostic and surgical management strategy, the fertility preservation and surveillance strategy in Borderline Ovarian Tumor (BOT). No screening modality can be proposed in the general population. An expert pathological review is recommended in case of doubt concerning the borderline nature, the histological subtype, the invasive nature of the implant, for all micropapillary/cribriform serous BOT or in the presence of peritoneal implants, and for all mucinous or clear cell tumors (grade C). Macroscopic MRI analysis should be performed to differentiate the different subtypes of BOT: serous, seromucinous and mucinous (intestinal type) (grade C). If preoperative biomarkers are normal, follow up of biomarkers is not recommended (grade C). In cases of bilateral early serous BOT with a desire to preserve fertility and/or endocrine function, it is recommended to perform a bilateral cystectomy if possible (grade B). In case of early mucinous BOT, with a desire to preserve fertility and/or endocrine function, it is recommended to perform a unilateral adnexectomy (grade C). Secondary surgical staging is recommended in case of serous BOT with micropapillary appearance and uncomplete inspection of the abdominal cavity during initial surgery (grade C). For early-stage serous or mucinous BOT, it is not recommended to perform a systematic hysterectomy (grade C). Follow up after BOT must be pursued for more than 5 years (grade B). Conservative treatment involving at least the conservation of the uterus and a fragment of the ovary in a patient wishing to conceive may be proposed in advanced stages of BOT (grade C). A new surgical treatment that preserves fertility after a first non-invasive recurrence may be proposed in women of childbearing age (grade C). It is recommended to offer a specialized consultation for Reproductive Medicine when diagnosing BOT in a woman of childbearing age. Hormonal contraceptive use after serous or mucinous BOT is not contraindicated (grade C).