Biomedical subjects
Publications and source records attributed to M S Hoffman.
There have been five previous well-documented cases of metastatic vulvar basal cell cancer in the literature. We now present the sixth case-an 86-year-old patient with vulvar basal cell cancer metastatic to an ipsilateral groin node. She was treated with radical vulvectomy and bilateral inguinofemoral lymphadenectomy and remains free of disease 1 year later.
In order to prevent the complications of long-term nasogastric suctioning and increase patient comfort, we have been using gastrostomy tubes (G-tubes) in gynecologic oncology patients who are deemed to be at risk for protracted postoperative bowel dysfunction. This study describes our patient selection criteria and evaluates the results with 35 MIC (Medical Innovation Corporation, Milpitas, CA) gastrostomy tubes inserted between September 1, 1992 and April 30, 1993. The procedure is technically easy and adds approximately 10 min to operating time. The tubes were well tolerated by the patients over periods ranging from 5 to 135 days. All tubes were used for postoperative gastric drainage and in addition, eight tubes were used for short-term enteral feeding. One patient with short bowel syndrome continued enteral nutritional supplementation at home. Twenty patients were discharged with their G-tubes in situ. Five of these patients required continuous gastric drainage because of obstruction of gastric emptying or small bowel by advanced tumor, and four of them were taking full liquids orally prior to discharge from the hospital. Gastrostomy tubes are convenient adjuncts to postoperative care of the gynecologic oncology patient and afford palliation with few complications to patients dying with bowel obstruction.
The pudendal thigh is a sensate fasciocutaneous flap supplied by the posterior labial artery. We report on the results of pudendal thigh flaps used for vaginal reconstruction in eight patients at the time of pelvic exenteration (6) and radical vaginectomy (2). Patients were interviewed and results were assessed 5 to 19 months after surgery. The flaps were raised in the thigh creases just lateral to the hair bearing area of the labia majora and included skin, subcutaneous tissues, deep fascia of the thigh, and the epimysium of the adductor muscles. Flap sizes varied from 9 x 4 cm to 15 x 6 cm. Bilateral flaps were used in seven patients. The flaps were technically easy to perform. Partial (apical) flap necrosis occurred in four patients. One patient developed complete necrosis of bilateral flaps, followed by an enterovaginal fistula. One patient whose flaps did not necrose developed a rectovaginal fistula at the site of rectal reanastomosis. The functional results are disappointing. The only patient having successful vaginal intercourse had a unilateral flap reconstruction following lower vaginectomy in a nonirradiated pelvis. No patient with bilateral flaps or prior pelvic irradiation has had successful coitus. Other long-term sequelae include vulvar pain (2), chronic vaginal discharge (2), hair growth (4), and protrusion of the flaps (2). These vulvovaginal symptoms discourage patients and their partners from genital contact. Breaching the integrity of the vulva to construct a neovagina that is likely to be unsuitable for sexual intercourse may deprive women of their only potential for normal genital sexual responsiveness. Techniques of vaginoplasty require continued assessment.
This is an evaluation of our experience with colorectal reanastomosis on a gynecologic oncology service. A retrospective review was carried out on all patients who underwent colorectal resection and reanastomosis on the gynecologic oncology service from October 1, 1987 to September 30, 1992. Thirty-nine procedures were performed: Nine patients underwent sigmoidectomy alone, 20 also underwent cytoreduction, and 10 also underwent exenteration. Thirty-eight percent of the patients had undergone prior radiotherapy. The level of anastomosis above the anal verge was 3-5 cm in 9 patients, 6-9 cm in 20 patients, and 10-14 cm in 10 patients. Sixteen had a protective colostomy which included 13 of the 15 patients with prior radiotherapy. Thirteen of the protective colostomies were taken down, although three of these required a second permanent colostomy. Three other patients required colostomy at a later date, one of whom developed a rectovaginal fistula 10 days following exenteration for postradiation recurrent carcinoma of the cervix. A total of 30 of the 37 evaluable patients (81%) had an ultimately functional colorectal reanastomosis. Problems related to colorectal function included stricture (4), fistula (4), chronic diarrhea (3), tenesmus (1), and fecal incontinence (1). Colorectal anastomosis is a worthwhile endeavor in selected patients with gynecologic cancer.
Eleven patients undergoing inguinofemoral lymphadenectomy for carcinoma of the vulva had the femoral vessels covered with Dura Film (Codman, Randolph, MA); a total of 21 groins were explored. The Dura Film was sutured to the inguinal ligament, sartorius muscle fascia, and adductor longus fascia. Nine of the 21 groins became infected with 3 of these breaking down; each of these 3 required removal of the Dura Film to achieve satisfactory healing. One patient developed a unilateral inflammatory groin mass requiring surgical removal of the Dura Film. One patient developed a chronic draining sinus that required surgical intervention. Seven groins developed lymphocysts. The morbidity was high with 9 of the 11 patients experiencing complications. Coverage of the femoral vessels with Dura Film after inguinofemoral lymphadenectomy is not an effective alternative to human dura mater or sartorius muscle transplant.
OBJECTIVE: The purpose of this study was to compare the intraoperative and postoperative complications of transvaginal morcellation and abdominal hysterectomy for the removal of moderately enlarged uteri. STUDY DESIGN: An observational study was performed on all uteri weighing > 200 gm removed transvaginally from July 1, 1987, to June 30, 1993. An abdominal hysterectomy control group was selected. RESULTS: There were 50 patients in the vaginal group and 112 in the abdominal group. At a p value < 0.05 there was no statistically significant difference between the two groups for age, parity, obesity, hypertension, insulin-dependent diabetes mellitus, or prior genitourinary surgery. The mean operative time in the vaginal hysterectomy group was 122 minutes and in the abdominal hysterectomy group 148 minutes (p < 0.05). The mean estimated blood loss was 527 and 586 ml, respectively (not significant). Twenty-two percent of the vaginal group and 70% of the abdominal group underwent bilateral oophorectomy (p < 0.05). The mean uterine weights were 335 and 336 gm, respectively (not significant). The mean day of starting a regular diet was 2.1 and 3.6, respectively (p < 0.05). The mean day of discharge was 3.6 and 5.1, respectively (p < 0.05). Complications were similar for the two groups. CONCLUSIONS: In selected patients transvaginal morcellation is a safe and effective alternative to abdominal hysterectomy for the removal of moderately enlarged uteri. The two procedures are comparable in operative time, blood loss, and complications. Both ovaries are more likely to be removed with abdominal hysterectomy. Cosmesis and recuperation may be advantages of the vaginal approach.
From 7/1/85 to 6/31/92 25 colostomy closures were performed. Twenty-one of the colostomies were performed in relation to gynecologic cancer and the remaining 4 were performed for benign pelvic disease. Nineteen patients underwent simple closure of a transverse loop colostomy. The other 6 patients had their colostomy closed in association with a laparotomy. There were no intraoperative complications related to the colostomy closure. There was 1 postoperative mortality secondary to adult respiratory distress syndrome following reoperation for stricture in the early postoperative period. Three other patients also experienced significant postoperative complications for an overall complication rate of 16%. These included one subcutaneous wound dehiscence, one subcutaneous wound infection, and one anastomotic stricture. One patient required a second colostomy due to recurrence of an obstruction by ovarian cancer in the rectosigmoid area. From the results of this small study, it would appear that colostomy closure is a reasonable endeavor in a selected group of gynecologic cancer patients.
Metastatic disease from nonvulvar gynecologic malignancies involving the groin lymph nodes is uncommon. The purpose of this study is to analyze the morbidity, recurrence-free interval, and survival in this group of surgically managed patients. Twenty patients underwent surgical resection of metastatic disease involving the groin lymph nodes between January 1, 1984 and December 31, 1991. Individual factors which have an impact on morbidity, recurrence, and survival were analyzed. Two patients developed wound infection and 2 had wound breakdown. Both of the patients with postoperative wound infection had clinically fixed nodes. None of the patients developed deep venous thrombosis. Long-term complications included lymphocytes in 2 patients and lymphedema in 4 patients. The median local disease progression-free interval was 10 months, with 5 of 20 patients developing local recurrence. The overall median survival was 11 months, with an adjusted 5-year survival rate of 11.5%. Patients with clinically fixed lymph nodes had a shorter median survival (3.6 months) than those with clinically mobile (median, 22.6 months) nodes (P = 0.0032). Metastatic disease from carcinoma of the ovary, fallopian tube, uterus, and cervix involving the groin lymph nodes can be managed safely and effectively with surgical resection. The acute and long-term morbidity is acceptable. Local control can be achieved in the majority of patients.
There is a demand on gynecologic oncology services for semipermanent cannulization of central veins to improve the quality of life in cancer patients by circumventing the need for frequent peripheral venous punctures. Central venous thrombosis and sepsis are the major complications with these lines. We reviewed our experience with the externalized Groshong catheters and subcutaneously implanted Hickman ports in 104 gynecologic oncology patients requiring either chemotherapy (56), hyperalimentation (5), or supportive care (43). All devices were inserted under the supervision of one primary gynecologic oncologist. Groshong catheters and Hickman ports remained in place for a median of 68.5 and 210 days, respectively (P < 0.001). Thrombosis occurred in association with 4.8% of catheters and was exclusive to the Groshong catheters. Line sepsis occurred in 32% of Groshong catheters and 16.2% of Hickman ports (P = 0.04). Infection rates were not higher in dual-lumen compared to single-lumen Groshong catheters. Staphylococcus epidermidis was the comments isolate in line infections. The majority of lines were salvaged despite infectious complications. Malfunction of the catheter was equally common in both groups (10.5-13.5%), but was complete, necessitating replacement of only 2.9% of lines. The Groshong catheters took less time to insert (P < 0.003). The externalized Groshong catheter remains a useful alternative to the subcutaneously implanted ports, especially when relatively short-term use is anticipated, but gynecologic oncologists should be aware that there is an increased frequency of complications with the externalized catheter.
OBJECTIVE: The purpose of the study was to determine the effect of cold therapy on the subjective assessment of pain, analgesic requirements, and wound complications in female patients undergoing major abdominal surgery. STUDY DESIGN: Twenty-seven patients were entered in the study in a prospective, randomized fashion. The Hot/Ice Thermal Blanket was applied to 13 patients, and 12 patients were in the control group. All patients underwent exploratory laparotomy and received postoperative pain relief with intravenously self-administered morphine sulfate through a patient-controlled analgesic pump. RESULTS: Compared with the control group (0.363 +/- 0.118 mg/kg/day), the cold pack group used more morphine sulfate on the first postoperative day (0.529 +/- 0.236 mg/kg/day, p < 0.05). The mean amount of morphine sulfate used by both groups was similar on postoperative day 2. CONCLUSION: We conclude that the cold pack does not improve postoperative pain control in gynecologic patients undergoing exploratory laparotomy.
We report three cases of abdominal wall metastases from ovarian cancer after laparoscopy. The implants occurred at the site of insertion of laparoscopy trocars. One patient had an implant of serous papillary carcinoma of low malignant potential at the trocar sites after laparoscopic oophorectomy. Laparoscopic surgery is inappropriate in patients with malignant ascites or when preoperative or intraoperative findings are suggestive of ovarian cancer.
OBJECTIVE: To evaluate the effect of intermittent pneumatic leg compression on intracranial pressure and cerebral perfusion pressure in brain-injured patients. DESIGN: Prospective, sequential patient study. SETTING: Surgical/trauma ICU of a community hospital providing regional trauma care. PATIENTS: Twenty-four adult, brain-injured patients (mean Glasgow Coma Scale score = 6) who required hemodynamic and intracranial pressure monitoring. INTERVENTIONS: Placement of intermittent sequential pneumatic leg compression devices for prevention of venous thrombosis. MEASUREMENTS: Mean arterial pressure (MAP), heart rate, central venous pressure, and intracranial pressure were measured at baseline, and at 0, 10, 20, and 30 mins of intermittent pneumatic leg compression. Cerebral perfusion pressure was calculated as the difference between MAP and intracranial pressure. RESULTS: No significant changes in MAP, central venous pressure, or intracranial pressure occurred during the study interval. Calculated cerebral perfusion pressure remained unchanged. A total of 23 of 24 study patients had intracranial pressure controlled by hyperventilation or pharmacologic measures within the normal range at the time of study. CONCLUSION: Intermittent pneumatic leg compression results in no significant changes in intracranial pressure or cerebral perfusion pressure in stable, brain-injured patients who have intracranial pressure controlled by medical means.
From January 31, 1990 to November 15, 1991, I treated three patients by cesarean hysterectomy with cervical conization for cervical neoplasia. All three hysterectomies were facilitated by the use of a combined abdominal-vaginal technique, which is described in this report.
The efficacy of single agent chemotherapy with methotrexate in low risk gestational trophoblastic disease is well established, but efforts to reduce toxicity and patient time and cost continue. Twenty-five patients with nonmetastatic postmolar gestational trophoblastic disease were seen by the Division of Gynecologic Oncology at the University of South Florida between February 1986 and December 1991. Patients were treated with either weekly intramuscular methotrexate 40 mg/M2 (Group 1, n = 13) or alternating doses of intramuscular methotrexate 1 mg/kg and folinic acid 0.1 mg/kg over eight consecutive days with an eight- day interval (Group 2, n = 12). Patient age, body weight and pre-treatment beta-hCG values were similar in the two groups. One patient defaulted from treatment and was lost to follow-up. All other patients were cured. Complete remission was achieved with primary chemotherapy in nine (69%) patients in Group 1 and nine (75%) in Group 2. All patients with pre-treatment beta-hCG of 650 mIU/ml or less responded to primary therapy whereas 50% of those with higher levels required second-line therapy. When secondary and tertiary treatment were included, the duration of treatment was similar in both groups. Remission was achieved at significantly lower levels of methotrexate in group 1 patients (p < 0.001). No major toxicities occurred. Side effects were gastrointestinal and myelosuppressive and occurred in 2.5% and 15.6% of treatment cycles in Groups 1 and 2, respectively (p < 0.01). Weekly methotrexate is an equally effective and less toxic regimen than eight-day methotrexate-folinic acid in nonmetastatic postmolar gestational trophoblastic disease.
Carcinoma of the vagina is optimally treated primarily with teletherapy, followed by interstitial needle brachytherapy. Following teletherapy, identification of the original tumor site is frequently difficult. We describe a method of marking the tumor with an india ink "tattoo" at initial presentation, followed by placement of a purse-string suture and titanium hemoclips at the time of brachytherapy. A stable marker is created so that the location of the original vaginal tumor can be easily identified on dosimetric films.
OBJECTIVE: To report our institutional experience with the accuracy and usefulness of cervical conization with frozen section before planned hysterectomy. METHODS: One hundred fifty-nine patients who planned to have hysterectomies for or with a concomitant diagnosis of cervical intraepithelial neoplasia (CIN) underwent preliminary cone biopsies with frozen section. The frozen and permanent pathologic diagnoses were compared retrospectively. Detailed analysis was directed at the indications for cone biopsy and the patients who were found to have invasive cancer. RESULTS: Among 108 patients with negative specimens or CIN, the frozen section was accurate within one degree of CIN in 106. Cone biopsy for a positive endocervical curettage, unsatisfactory colposcopy, or discrepant cytology did not contribute to the diagnosis of invasive cancer but did lead to an ultimate diagnosis of CIN III. One of 12 women with a frozen-section diagnosis of microinvasion had deeper invasion on permanent sections. CONCLUSIONS: Frozen-section evaluation of a cone biopsy carries a degree of accuracy that enables the surgeon to make an immediate decision about definitive therapy. Exact indications, use during pregnancy, and accuracy for the diagnosis of microinvasion require further study.
OBJECTIVE: To evaluate and compare the cytologic information obtained from the endocervical brush and the histologic information obtained from the standard endocervical curettage (ECC) used to evaluate the endocervical canal in patients with an abnormal Papanicolaou test. METHODS: Three hundred eighty-eight patients underwent evaluation of an abnormal Papanicolaou test with a repeat Papanicolaou test, a separate endocervical brush test, colposcopy, directed biopsies, and ECC. The study group comprised 101 patients who subsequently underwent conization and/or hysterectomy. The brush and ECC results were evaluated against the final pathologic findings. RESULTS: Sixty-five patients had a satisfactory colposcopy and 36 had an unsatisfactory colposcopy. Results for these two groups are reported separately. For the total group, the sensitivities of the ECC and brush were 49 and 93%, respectively (P < .001); the specificities were 82 and 26% (P < .001), the positive predictive values were 69 and 52% (P = .99), and the negative predictive values were 65 and 82% (P = .004). CONCLUSION: The endocervical brush appears to be a sensitive test for disease in the endocervical canal but yields a high false-positive rate. The role of the brush in this setting will require further study. The ECC is more specific but is also a suboptimal test for identifying disease in the endocervical canal.
BACKGROUND: The majority of ureteric injuries associated with an operation are the result of gynecologic surgery. Thus, gynecologists must be aware of this risk and appreciate that ureteric injury can present late and in an unusual manner. CASE: A 26-year-old woman presented with gross abdominal distention 4 months after total abdominal hysterectomy. Ultrasonography demonstrated a large volume of ascitic fluid and a complex cyst arising from the left ovary. Serum blood urea nitrogen and creatinine were normal. Laparotomy showed a mass of 1-2-cm cysts (urinomas) on the pelvic peritoneum and tubo-ovarian surfaces and a right hydroureter with a right ureteric fistula at the level of the ureteric tunnel. A ureteroneocystostomy was performed. CONCLUSION: Ureteroperitoneal fistula with urinary ascites is a rare complication of pelvic surgery. Intravenous urography or computed tomography scan would have helped establish the diagnosis.