Impact of surgical site infection (SSI) following gynaecological cancer surgery in the UK: a trainee-led multicentre audit and service evaluation.

OBJECTIVES: Surgical site infection (SSI) complicates 5% of all surgical procedures in the UK and is a major cause of postoperative morbidity and a substantial drain on healthcare resources. Little is known about the incidence of SSI and its consequences in women undergoing surgery for gynaecological cancer. Our aim was to perform the first national audit of SSI following gynaecological cancer surgery through the establishment of a UK-wide trainee-led research network. DESIGN AND SETTING: In a prospective audit, we collected data from all women undergoing laparotomy for suspected gynaecological cancer at 12 specialist oncology centres in the UK during an 8-week period in 2015. Clinicopathological data were collected, and wound complications and their sequelae were recorded during the 30 days following surgery. RESULTS: In total, 339 women underwent laparotomy for suspected gynaecological cancer during the study period. A clinical diagnosis of SSI was made in 54 (16%) women. 33% (18/54) of women with SSI had prolonged hospital stays, and 11/37 (29%) had their adjuvant treatment delayed or cancelled. Multivariate analysis found body mass index (BMI) was the strongest risk factor for SSI (OR 1.08[95% CI 1.03 to 1.14] per 1 kg/m2 increase in BMI [p=0.001]). Wound drains (OR 2.92[95% CI 1.41 to 6.04], p=0.004) and staple closure (OR 3.13[95% CI 1.50 to 6.56], p=0.002) were also associated with increased risk of SSI. CONCLUSIONS: SSI is common in women undergoing surgery for gynaecological cancer leading to delays in discharge and adjuvant treatment. Resultant delays in adjuvant treatment may impact cancer-specific survival rates. Modifiable factors, such as choice of wound closure material, offer opportunities for reducing SSI and reducing morbidity in these women. There is a clear need for new trials in SSI prevention in this patient group; our trainee-led initiative provides a platform for their successful completion.

Diagnostic accuracy of magnetic resonance imaging in endometrial cancer.

OBJECTIVES: The objectives of this study were to investigate the accuracy of magnetic resonance imaging (MRI) in predicting the depth of myometrial invasion in the preoperative assessment of women with endometrial cancer and to quantify the impact of MRI as an adjunct to predicting patients requiring full surgical staging. METHODS: This was a diagnostic accuracy study of prospective cases in conjunction with STARD guidelines using collected data from a tumor board within a cancer network. Consecutive series of all endometrial cancers in Northern Ireland over a 21-month period was discussed at the Gynaecological Oncology Multidisciplinary Team/tumor board meeting. This study concerns 183 women who met all the inclusion criteria. Main outcome measure was the correlation between the depth of myometrial invasion suggested by preoperative MRI study and the subsequent histopathological findings following examination of the hysterectomy specimen. Secondary end point was how MRI changed management of women who required surgery to be performed at a central cancer center. RESULTS: For the detection of outer-half myometrial invasion, overall sensitivity of MRI was 0.73 (95% confidence interval [CI], 0.59-0.83), and specificity was 0.83 (95% CI, 0.76-0.89). The positive predictive value was 0.63 (95% CI, 0.50-0.74), and negative predictive value was 0.89 (95% CI, 0.82-0.93). Positive likelihood ratio was 4.35 (95% CI, 2.87-6.61), and negative likelihood ratio was 0.33 (95% CI, 0.21-0.52). Magnetic resonance imaging improved the sensitivity and negative predictive value of endometrial biopsy alone in predicting women with endometrial cancer who require full surgical staging (0.73 vs 0.65 and 0.80 vs 0.78, respectively). CONCLUSIONS: Preoperative pelvic MRI is a moderately sensitive and specific method of identifying invasion to the outer half of myometrium in endometrial cancer. Addition of MRI to preoperative assessment leads to improved preoperative assessment, triage, and treatment.

Radical excision of vulval disease and multidisciplinary tissue flap reconstruction: the belfast experience.

OBJECTIVE: The aim of this study was to compare Belfast City Hospital's vulval flap reconstructive surgery with recognized standards and published data to facilitate modifications to practice. MATERIALS AND METHODS: Retrospective cohort study involving women who underwent vulval reconstructive skin flap procedures from January 1, 2004, through December 31, 2009. RESULTS: A total of 25 women underwent 28 flaps; age range was 41 to 90 years and mean parity was 2.1. Indications for surgery were recurrence of cancer in 11 (44%) of the 25 women, benign disease in 6 women (24.0%), primary vulval cancer in another 6 women (24.0%), and vulval intraepithelial neoplasia in 2 women. Thirteen women (52.0%) within the study had undergone previous radical vulval excision. Wide local excision was performed in 14 women (56.0%), with 5 undergoing radical vulvectomy and 6 undergoing modified radical vulvectomy. There were 15 (53.6%) of the 28 lotus flaps, 6 (21.4%) rhomboid-type repairs, and 3 (10.7%) gracilus flaps.Intensive care unit admission immediately after operation was required in 2 (8.0%) of the 25 women. Return to the operating theater was required in 5 cases (20.0%). Hospital stay ranged from less than 1 week to greater than 6 weeks, the mode being 8 to 14 days and mean being 21.5 days. A total of 16 (64.0%) of the 25 cases experienced wound infection with or without breakdown, with 12 cases (48.0%) having wound infection. There were 10 cases (40.0%) of partial or complete wound breakdown. Necrosis of wound (5 cases) and lymphocyst (2 cases) were less common. Twelve women (48.0%) experienced some form of medical postoperative complication(s), whereas 15 women (60.0%) had no long-term complications. CONCLUSIONS: The rate of local flap procedure is higher than that published elsewhere, whereas the postoperative complication rate is comparable and adherent to accepted standards. Perioperative protocols have been reported to improve complication rates, and this strategy has been adopted in Belfast.

Peritoneal bile granulomas identified at Cesarean section and mimicking disseminated malignancy.

A 37-year-old woman was found to have multiple peritoneal nodules, including on the uterine serosa, at Cesarean section. Histology showed yellow crystalline material surrounded by histiocytes and occasional multinucleate giant cells. Further enquiry revealed that the patient underwent a cholecystectomy for a perforated gallbladder 3 years earlier. Pathologists should be aware of this uncommon complication of bile leakage, which has the potential to clinically mimic disseminated malignancy. This may become increasingly common in the future since bile leakage is more likely to occur with laparoscopic than open cholecystectomy.