Short-term outcomes in patients undergoing laparoscopic surgery for deep infiltrative endometriosis with rectal involvement: a single-center experience of 168 cases

Purpose@#The surgical management of deep infiltrative endometriosis (DE) involving the rectum remains a challenge. The objective of this study was to assess the outcomes from a single tertiary center over a decade with an emphasis on the role of a protective loop ileostomy (PI). @*Methods@#A retrospective review of outcomes for 168 patients managed between 2008 and 2018 is presented including 57 rectal shaves, 23 discoid excisions, and 88 segmental rectal resections. @*Results@#The nodule size (mean±standard deviation) in the segmental resection group was 32.7±11.2 mm, 23.4±10.5 mm for discoid excision, and 18.8±6.0 mm for rectal shaves. A PI was performed in 19 elective cases (11.3%) usually for an ultra-low anastomosis <5 cm from the anal verge. All Clavien-Dindo grade III/IV complications occurred after segmental resections and included 5 anastomotic leaks, 6 rectovaginal fistulas, 2 ureteric fistulas, and 1 ureteric stenosis. Of 26 stomas (15.5%), there were 19 PIs, 3 secondary ileostomies (after complications), and 4 end colostomies. The median time to PI closure was 5.8 months (range, 0.4–16.7 months) in uncomplicated disease compared with 9.2 months (range, 4.7–18.4 months) when initial postoperative complications were recorded (P=0.019). Only 1 patient with a recurrent rectovaginal fistula had a permanent colostomy. @*Conclusion@#In patients with DE and rectal involvement a PI is selectively used for low anastomoses and complex pelvic reconstructions. Protective stomas and those used in the definitive management of a major postoperative complication can usually be reversed.

Effect of tumor burden and radical surgery on survival difference between upfront, early interval or delayed cytoreductive surgery in ovarian cancer / 부인종양

Objective@#We sought to evaluate the impact on survival of tumor burden and surgical complexity in relation to the number of cycles of neoadjuvant chemotherapy (NACT) in patients with advanced ovarian cancer (OC) with minimal (CC-1) or no residual disease (CC-0). @*Methods@#This retrospective study included patients with International Federation of Gynaecology and Obstetrics IIIC–IV stage OC who underwent debulking surgery at 4 high-volume institutions between January 2008 and December 2015. We assessed the overall survival (OS) of primary debulking surgery (PDS group), early interval debulking surgery after 3–4 cycles of NACT (early IDS group) and delayed debulking surgery after 6 cycles (DDS group) with CC-0 or CC-1 according to peritoneal cancer index (PCI) and Aletti score. @*Results@#Five hundred forty-nine women were included: 175 (31.9%) had PDS, 224 (40.8%) early IDS and 150 (27.3%) DDS. Regardless of Aletti score, median OS after PDS was significantly higher than after early IDS or DDS, but the survival difference was higher in women with an Aletti score 10, there were no differences between PDS and early IDS, but DDS was associated with decreased OS. @*Conclusion@#The benefit of complete PDS compared with NACT was maximal in patients with a low complexity score. In patients with low tumor burden, there was a survival benefit of PDS over early IDS or DDS. In women with high tumor load, DDS impaired the oncological outcome.

The extent of aortic lymphadenectomy in locally advanced cervical cancer impacts on survival / 부인종양

Objective@#The prognostic impact of surgical paraaortic staging remains unclear in patients with locally advanced cervical cancer (LACC). The objective of our study was to evaluate the results of the surgical technique of preoperative aortic lymphadenectomy in LACC related to tumor burden and disease spread to assess its influence on survival. @*Methods@#Data of 1,072 patients with cervical cancer were taken from 11 Spanish hospitals (Spain-Gynecologic Oncology Group [GOG] working group). Complete aortic lymphadenectomy surgery (CALS) was considered when the lymph nodes (LNs) were excised up to the left renal vein. The extent of the disease was performed evaluating the LNs by calculating the geometric means and quantifying the log odds between positive LNs and negative LNs. The Kaplan-Meier method was used to estimate the survival distribution. A Cox proportional hazards model was used to account for the influence of multiple variables. @*Results@#A total of 394 patients were included. Pathological analysis revealed positive aortic LNs in 119 patients (30%). LODDS cut-off value of −2 was established as a prognostic indicator. CALS and LODDS <−2 were associated with better disease free survival and overall survival than suboptimal aortic lymphadenectomy surgery and LODDS ≥−2. In a multivariate model analysis, CALS is revealed as an independent prognostic factor in LACC. @*Conclusion@#When performing preoperative surgical staging in LACC, it is not advisable to take simple samples from the regional nodes. Radical dissection of the aortic and pelvic regions offers a more reliable staging of the LNs and has a favorable influence on survival.

Accuracy of detection rate and intraoperative sentinel lymph node assessment in early-stage cervical carcinoma

Objective: This study was aimed at evaluating the usefulness of paired box-2 gene (PAX-2) in the diagnosis of renal tumors. Materials and Methods: This study included 60 renal tumors. The newly prepared hematoxylin and eosin stained slides of all cases were evaluated and the diagnoses were confirmed or revised for each tumor according to the 2004 World Health Organization classification of renal tumors. Representative and consecutive sections of each tumor were submitted for anti-PAX-2 antibody immunohistochemistry. The pattern of staining (nuclear or cytoplasmic) was also noted. PAX-2 expression in tumors was correlated with low- and high-nuclear grades (Fuhrman nuclear grades). Results: The 45/60 (75%) cases showed PAX-2 nuclear immunoexpression. The frequency of positivity in renal tumors was seen in 29/34 (85.5%) and 12/15 (80%) cases of clear cell RC, papillary RCC, respectively. The PAX-2 was positive in 20/45 cases for score 1+. The 16/45 cases were categorized into score 2+, and 9/45 cases were categorized into score 3+. Conclusion: PAX-2 is a diagnostically useful marker for primary renal tumors and is inversely proportion to the grades of the renal tumor.

Influencia en la evolución de los pacientes con bacteriemia/candidemia de la participación activa del especialista clínico en Patología Infecciosa. Estudio de una cohorte prospectiva / The impact of Infectious Disease specialist active care on the outcome of patients with bacteraemia/candidemia. A prospective cohort study María Encarnación Hernández Contrerasa

Introducción: Nuestro objetivo es evaluar el impacto de la participación activa del especialista en Patología Infecciosa en el pronóstico de los enfermos con bacteriemia/candidemia. Pacientes y métodos: Estudio observacional, longitudinal y prospectivo de una cohorte de pacientes con bacteriemia/candidemia en un hospital de tercer nivel (2010-2011). Se analizaron los factores asociados con fracaso terapéutico (persistencia de la bacteriemia/candidemia o muerte relacionada) mediante análisis bivariante y multivariante. Resultados: Se valoraron un total de 324 episodios de bacteriemia/candidemia significativa, de los que en 252 pacientes (78%) el Servicio de Medicina Interna Infecciosas aplicó un sistema de participación activa (recomendación sobre el tratamiento antibiótico). La adquisición de la bacteriemia se consideró nosocomial o relacionada con cuidados sanitarios en 154 pacientes (47,5%) y comunitaria en 170 (52,5%). Los focos de infección más frecuentemente identificados fueron: urinario (31%), catéter vascular (14%), intraabdominal (12%) y desconocido (15%). El 31,6% era portador de sonda vesical y el 35,4%, de catéter venoso central. El 24% de los pacientes no presentaban fiebre (>38 °C) en el momento de cursar los hemocultivos. La bacteriemia fue persistente en 35 pacientes (11%). La mortalidad global fue del 17,4% y del 15% relacionada ("fracaso" terapéutico, 20%). Se asociaron a un mayor fracaso terapéutico el índice de Pitt ≥ 3 (OR 7,94), McCabe III (OR 3,11), uso previo de antibióticos (OR 2,93) y la ausencia de participación activa de los especialistas clínicos en Patología Infecciosa (OR 2,44). Conclusiones: En la cohorte de pacientes con bacteriemia/candidemia estudiada, la gravedad de la enfermedad de base, la gravedad al inicio, el uso previo de antibióticos y la ausencia de participación activa de los especialistas clínicos en Patología Infecciosa se asociaron a fracaso terapéutico.

Introduction: Our objective is to evaluate the impact of active care by an Infectious Diseases specialist (IDS) on the outcome of patients with bacteraemia/candidemia. Patients and methods: Observational, longitudinal and prospective study of a cohort of patients with bacteraemia/candidemia in a tertiary level hospital (2010-2011). Factors associated with treatment failure (persistent bacteraemia or related death) were analysed (bivariate and multivariate analysis). Results: A total of 324 episodes of bacteraemia were included, of which surveillance by IDS was implemented in 252 cases (78%). Acquisition was considered nosocomial or healthcare-related in 154 patients (47.5%) and community acquired in 170 (52.5%). More frequent sources of bacteraemia were urinary tract (31%), vascular catheter (14%), intra-abdominal (12%); and unknown (15%); 31.6% had a urinary catheter and 35.4% had a central venous catheter. When blood cultures were processed, 24% of patients had no fever (> 38 °C). Bacteraemia was persistent in 35 patients (11%). Overall mortality was 17.4% and 15% related (therapeutic "failure", 20%). Failure was associated with Pitt ≥ 3 (OR 7.94), McCabe III (OR 3.11), previous use of antibiotics (OR 2.93) and no active care by IDS (OR 2.44). Conclusions: In our study cohort, severity at presentation, underlying medical conditions, previous antibiotic use and no active Infectious Diseases specialist care were statistically associated with mortality or microbiological failure.

Prognostic factors associated with local recurrence in squamous cell carcinoma of the vulva / 부인종양

OBJECTIVE: To analyze the prognostic factors related to the recurrence rate of vulvar cancer. METHODS: Retrospective study of 87 patients diagnosed of vulvar squamous cell carcinoma diagnosed at a tertiary hospital in Madrid between January 2000 and December 2010. RESULTS: The pathological mean tumor size was 35.1+/-22.8 mm, with stromal invasion of 7.7+/-6.6 mm. The mean free margin after surgery was 16.8+/-10.5 mm. Among all patients, 31 (35.6%) presented local recurrence (mean time 10 months; range, 1 to 114 months) and 7 (8%) had distant metastases (mean time, 5 months; range, 1 to 114 months). We found significant differences in the mean tumor size between patients who presented a relapse and those who did not (37.6+/-21.3 mm vs. 28.9+/-12.1 mm; p=0.05). Patients with free margins equal or less than 8 mm presented a relapse rate of 52.6% vs. 43.5% of those with free margin greater than 8 mm (p=0.50). However, with a cut-off of 15 mm, we observed a local recurrence rate of 55.6% vs. 34.5%, respectively (p=0.09). When the stromal invasion cut-off was >4 mm, local recurrence rate increased up to 52.9% compared to 37.5% when the stromal invasion was 4 mm, high risk predictors of local recurrence rate.