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Gynecologic Surgery

OB.GYN. NEWS • April 1, 2007

Sentinel-Node Biopsy Defines Risk in Vulvar Ca
BY ROBERT FINN

San Francisco Bureau

S A N T A M O N I C A , C A L I F. — It’s safe to rely on sentinel-node biopsy for assessing the risk of metastasis in women with earlystage vulvar cancer, Dr. Ate van der Zee said at the biennial meeting of the International Gynecologic Cancer Society. The results of a large, multicenter, observational study indicate that sentinel-node biopsy has a sensitivity of 95.4% in predicting whether unifocal vulvar cancer has metastasized, with a negative predictive value of 98.3%. These data come from a total of 367 women, median age 66 years, with stage T1 or T2 squamous cell cancer of the vulva,

Another two of the false negsaid Dr. van der Zee of the Uni- lymphadenectomy. The remainversity Medical Center Gronin- ing sentinel node–negative pa- atives were attributed to technitients were followed for a medi- cal error, and no explanation gen (the Netherlands). could be found for the remaining None of the patients had clin- an of 35 months. During that time, 8% of the three. ically suspicious groin nodes, and Among the 21 sentinel their sentinel nodes were detect- patients had a local recurrence of their cancer, and 2.9% had a node–negative patients with reed with radioactive tracer. current local disease, the Patients whose sentinelThe 3-year survival rate was median time to recurrence node biopsies were negawas 21 months, and 4 of tive did not have full lym96.5% among women who were the patients died. phadenectomies, but sentinel-node negative, and The 3-year survival rate rather were followed up was 96.5% among women closely by an experienced 80.5% among women who were who were sentinel-node physician. sentinel-node positive. negative, and 80.5% Physicians treated the among women who were primary tumor with a sentinel-node positive. wide local excision in 91% of the groin recurrence. There was significantly less Of the seven patients who had women, with the remainder receiving either radiotherapy or a groin recurrence, two had mul- short-term and long-term mortifocal disease, and the study pro- bidity among the sentinel radical vulvectomy. Overall, 32% of the patients tocol was subsequently amended node–negative women, comhad positive biopsies of sentinel to exclude women with multifo- pared with those who underwent lymphadenectomy. lymph nodes and went on to cal disease.

The women who underwent only sentinel-node biopsy had one-third the rate of wound breakdown and one-quarter the rate of cellulitis as did those who underwent lymphadenectomy. Moreover, the median length of stay in the hospital was significantly shorter for sentinel node–negative women. They also had much lower rates of recurrent erysipelas and lymphedema. Although he is enthusiastic about the potential for sentinelnode biopsy in women with vulvar cancer, Dr. van der Zee cautioned that this should be performed only by an experienced team, and preferably within the context of a clinical trial. ■

Preserve Ovarian Function ‘Muscle Welding’ Is Last, Best With Laparoscopic Detorsion Way to Stem Presacral Bleeding
B Y M I C H E L E G. S U L L I VA N

Mid-Atlantic Bureau

O R L A N D O — Laparoscopic untwisting of an adnexal torsion can almost always preserve ovarian function and avoid the need for an adnexectomy, Dr. Kazem Nouri said at a meeting on laparoscopy and minimally invasive surgery. “These days, there is no longer any question about whether laparoscopy or laparotomy is the best way to deal with adnexal torsion. The answer is laparoscopy,” said Dr. Nouri of the General Hospital of Vienna. “The question is whether to go with detorsion or removal of the adnexa,” he said. “In my opinion, detorsion is justified because even if the ovary appears devascularized, function can be preserved in almost all cases.” Ovarian torsion most often occurs in conjunction with a cyst and is seen more frequently in the right ovary than in the left. The symptoms include nonspecific abdominal pain, which can have either gradual or sudden onset and may radiate to the front, back, or groin. Nausea and vomiting are present in up to 70% of cases. The differential diagnosis includes appendicitis, ectopic pregnancy, pelvic inflammatory disease, diverticulitis, and renal colic. Torsion is usually diagnosed by abdominal or transvaginal ultrasound. The classic finding is the “whirlpool sign”—a spiraling line that shows the twisted pedicle. Ultrasound may also show an enlargement of the affected ovary and deviation of the uterus toward the affected side. “None of these findings has 100% specificity and sensitivity, however,” said Dr. Nouri. “The only way to be 100% sure is to do a diagnostic laparoscopy.”

Adnexal torsions have historically been treated by laparotomy with adnexectomy, he said. “Gynecologists were afraid of sepsis and pulmonary embolism associated with the torsion. And they were not that concerned about preserving the ovary because they held the opinion that after torsion, the ovary was nonfunctional.” The introduction of laparoscopic detorsion proved that ovarian function can be preserved in almost 90% of cases, Dr. Nouri said at the meeting sponsored by the Society of Laparoendoscopic Surgeons. In addition, the fear of pulmonary embolism associated with the condition appears unfounded. A 1999 review of about 600 patients treated with either laparoscopic detorsion or laparotomy with resection found only two cases of pulmonary embolism, both in women who underwent laparotomy. Embolism appeared to be associated with length of hospital stay: One woman was hospitalized 3 days before the surgery, and the other, 4 days. Laparoscopic detorsion involves careful manipulation of the adnexa, making sure to untwist the tissue in the correct direction. If there is a cyst, opinions are divided on whether to remove it at the time of the detorsion. “Reports in the literature mention that the cystectomy can be complicated by edematous tissue, and some advise waiting for 3 or 4 weeks before removing the cyst,” Dr. Nouri said. Other surgeons prefer to remove the cyst for immediate biopsy. “I have treated eight torsions, and in some cases I did the cystectomy later. In others I thought the ovary looked suspicious, so I performed it right away.” An oophorectomy is usually performed only in the case of recurrent torsion, he said. ■

BY MITCHEL L. ZOLER

Philadelphia Bureau

F O R T L A U D E R D A L E , F L A . — Anyone who operates in the pelvis should know how to manage presacral bleeding because it occasionally happens to most surgeons, Dr. Herand Abcarian said at an international colorectal disease symposium sponsored by the Cleveland Clinic Florida. “Muscle welding” is an effective way to stop presacral venous bleeding when other steps fail. In a series of 426 patients at the Mayo Clinic, Rochester, Minn., who had surgery for rectal cancer during the early 1990s, 3% had presacral bleeding. Dr. Abcarian’s suggested management sequence is initial tamponade with packing. The patient should be put in the reverse Trendelenburg’s position while exposure of the bleed is set up, followed by digital pressure and then attempted repair with suture, clips, cautery, or argon beam. If none of these work, a properly placed thumbtack can sometimes staunch the flow. But muscle welding is almost always effective as a last-ditch attempt to stop the bleeding before temporarily packing the patient and waiting a few days for the patient to stabilize. “By far it’s the most successful method for controlling presacral bleeding,” said Dr Abcarian, chairman and professor, department of surgery, the University of Illinois at Chicago. Welding is done by harvesting a 3- to 4-cm by 1- to 2-cm strip of rectus muscle from the lower abdominal incision, below the midline. The muscle is placed directly over the bleeding point, held there with the tip of a clamp, and treated with a cautery probe turned up to maximum coagulating power. The clamp should be withdrawn after a few seconds, once the patch sits firmly on its own, so that the clamp does not stick to

the burned muscle fragment. Continued cautery power is applied until the muscle takes on the appearance of shoe leather and becomes a coagulum that seals the bleeding point. A thumbtack may work, but only when it’s correctly applied. The tack must be placed over the bleeding point and forcefully driven into the anterior sacral table, causing a crunching of the bone. Collapsing the bone is vital for stopping flow because it’s the bone dropping into the sacral plexus that helps block further bleeding. Although placement of a second tack might occasionally be called for, placing multiple tacks should be avoided, Dr. Abcarian advised. When tacks and muscle welding fail to staunch the flow, packing for several days is the last resort. A layer of Silastic or a piece from a rubber glove is placed over the bleeding, and then the pelvis is packed tightly to produce tamponade. The patient should be stabilized and normalized for coagulation factors, hemoglobin, and vital functions, and returned to the operating room 3 days later to have the pack removed and the bleeding assessed. In rare cases when bleeding continues, the packing should be redone and the bleeding reassessed as needed until it stops. The most common cause of presacral bleeding is a forceful lifting of the rectum from the sacral surface and blunt dissection of the rectum in a narrow male pelvis. The best way to prevent a presacral bleed is by appropriately positioning the patient, using excellent exposure and lighted retractors, and by using sharp—not blunt—dissection. Sometimes it is tempting to simply pull the rectum straight up and out of the way, but this can cause a tear. “The less blunt dissection, the better,” Dr. Abcarian said. ■