A comparison of findings at second-look laparotomy with preoperative computed tomography in patients with ovarian cancer.

Prior to undergoing second-look laparotomy, 57 patients with ovarian cancer were evaluated with computed axial tomography (CT). All patients were clinically free of disease following chemotherapy. At laparotomy, 25 patients had visible evidence of disease, 9 had microscopic disease only, and 23 were free of cancer. Tumor was correctly identified on CT in 9 of the 25 patients (36%) with macroscopic disease. Tumors smaller than 2 cm in size were not detected by CT. CT suggested disease in 8 of the 32 patients (25%) who were free of macroscopic disease. CT provides useful information when it is abnormal. Fine needle aspiration of suspicious areas can spare some patients laparotomy. However, CT has a significant false-negative rate due to its inability to detect small volume disease. Patients with negative CT will continue to require reexploration and tissue confirmation to assess the need for further therapy.

Pitfalls in interpretation of computed tomography prior to second-look laparotomy in patients with ovarian cancer.

Fifty-seven patients with ovarian cancer were assessed with computed tomography (CT) prior to undergoing second-look laparotomy. All patients were clinically free of disease following chemotherapy. Patients were scanned from the top of the liver to the symphysis pubis using oral, rectal and intravenous contrast medium. Tumour was correctly identified on CT scan in nine of 25 patients who had visible evidence of cancer at laparotomy. However, in the remaining 16 patients peritoneal studding was present and was not detected. Tumours smaller than 1.5 cm in size were not found by CT scanning. Computed tomography showed abnormality in eight of 32 patients subsequently found to be free of disease. Fine-needle aspiration cytology, bolus contrast injection and repeat scanning with additional oral contrast medium could have assisted in these circumstances. As persistent disease is by definition, a contraindication to second-look laparotomy, aggressive pre-operative assessment will spare some patients unnecessary surgery. However, CT cannot detect the small nodules often present in ovarian cancer, and thus, normal scans cannot replace surgical restaging.

Group B streptococcal necrotizing fasciitis arising from an episiotomy.

A case of extensive necrotizing fasciitis arising from an episiotomy is presented. Group B beta-hemolytic streptococcus and Staphylococcus aureus were isolated. Prompt recognition and aggressive therapy resulted in a favorable outcome despite significant morbidity. Salient clinical features of this rare postpartum complication are discussed and previous cases are reviewed. In addition to wide surgical resection, therapy included aggressive volume resuscitation with Swan-Ganz catheter monitoring, the use of military antishock trousers (MAST suit) to control diffuse hemorrhage, and temporary application of porcine xenografts.

Second-look laparotomy after chemotherapy in the management of ovarian malignancy.

Eighty-eight patients with ovarian malignancy underwent second-look laparotomy as part of their plan of management at Indiana University Hospital. Thirty-five patients (39.8%) were found to have no gross or microscopic evidence of persistent neoplasm, and an additional 16 (18.2%) had only microscopic tumor. Patients with initial Stage III or IV disease were less likely to have negative findings at laparotomy than were patients with Stage I or II disease. A complete initial cytoreductive operation (residual disease = 0 cm) correlated positively with negative findings at laparotomy. Endometrioid histologic findings were associated with a favorable condition at the second look, but tumor grade was associated with superior survival only for patients with grade 0 disease. Eight of 30 patients (26.7%) with invasive carcinoma and negative findings at second-look laparotomy have had tumor recurrence (2 to 63 months), and five of eight have died. Intraperitoneal chromic phosphorus salvage therapy for patients with microscopic disease was promising, with eight of 15 treated patients (53.3%) alive after therapy, with no evidence of disease from 16 to 56 months after the second look. Second-look laparotomy has been the major determinant of continued or alternative therapy for patients with ovarian malignancy. Second-look laparotomy has been incorporated into the standard management plan without a formal clinical trial. The need for a second look may be reduced by identifying patients who do not benefit from the procedure. Patients with persistent disease confirmed by noninvasive means can continue therapy without laparotomy. There is also a subgroup of patients with a favorable prognosis whose therapy could be safely discontinued without laparotomy.