Complications in Gynecological Oncology

This quote provides a very good introduction to this chapter. Complications occur in all forms of gynecological surgery. They can be reduced by a variety of strategies. The view expressed by the consultant quoted above may reflflect a number of points. First, the consultant’s surgical workload or practice may be too small. Unless complications occur frequently, the practitioner with a small practice will not see many problems within an assessable time frame. Therefore, there will be a lack of insight with regard to these problems or even a selective memory, leading the practitioner to believe that his or her surgeries have few or no complications. This trend has been compounded in the National Health Service (NHS) by poor data collection and no agreement regarding the minimum data set relating to complications. Audit of outcomes and complications is sporadic and usually covers only a short time period. This defificit also leads to complacency with respect to complications.

In gynecological oncology surgery, there are some data relating to complications. Increasingly, we are dealing with a centralized service following the introduction of the Improving Outcomes Guidance in England and Wales [1]. This centralization and the introduction of mandatory minimum data-set collection will lead to more information about complications and should reduce the number of practitioners who subscribe to the opinion voiced in this chapter’s opening quote.

Radical Cancer Surgery

The aim of radical cancer surgery is in the fifirst instance curative. In ovarian cancer, surgery is diagnostic (providing histological material), needed for staging, and also therapeutic [2], regardless of the fifinal stage. In endometrial cancer, the surgery is the cornerstone of treatment even with advanced disease, providing information relating to stage as well [3]. In cervical cancer, surgery is reserved for curative intent in patients with early disease. In patients with recurrent cervical disease, surgery may be curative with exenteration [4] but is more often palliative to control symptoms.

Complications of Radical Surgery

Anesthetic and Perioperative Complications

The outcome of surgery depends in part on the patient’s fitness (see Figure 2.1). The patients we treat who have gynecological cancer usually comprise an older population than patients with other gynecological conditions. Considerable comorbidity is present in the gynecological cancer population; this comorbidity in itself leads to a higher rate of complication. In comparing outcomes, including hospital stay, these comorbidities should be taken into account. This may be addressed using an evaluation tool such as the “adult comorbidity evaluation-27” sheet [5], which may be used for the minimum cancer data set.

Perioperative death (within 24 hours) was 8.8. per 10,000 anesthesia administrations, with 85% of the deaths related to the patient’s comorbidity. Thus, selection of the appropriate operation for each patient is important. In the group of patients who died as a result of anesthetic-related problems, 25% were inadequately prepared for surgery [6].

Appropriate liaison with consultant anesthetists and suitable preoperative preparation of patients with gynecological cancer lead to better outcomes. The primary debulking surgery required for advanced ovarian cancer or the management of the patient for interval debulking surgery is not comparable to routine benign gynecological surgery, and therefore there is an intraoperative requirement for epidural usage, central venous and arterial monitoring, and postoperative high-dependency or intensive-care support.

Risk reduction relating to anesthesia can be achieved by the following practices:

• The use of an appropriately skilled anesthetist providing an apt preoperative assessment

• The use of intraoperative regional anesthesia in addition to general anesthesia, which leads to reduced amount of central sedation,

2. Complications in Gynecological Oncology

reduced effect on the gut motility postoperatively, and reduced thrombosis risk, as well as excellent postoperative analgesia

• Good postoperative care, with access to correctly staffed high-

dependency and/or intensive care In the gynecological oncology center, the anesthetist is an integral part of the multidisciplinary team.

Infection

In gynecological oncology, patients are at risk of infection in the chest, in the pelvis/intraabdominal region, in the urinary tract, at the wound site, and at sites of intravenous and arterial lines. Any prophylactic regime is effective in reducing postoperative infective complications [7]. It is important that the regime be given at the appropriate time. We have used a nurse-based “patient group directive” to ensure that all women undergoing surgery, whether elective or emergency, are covered by antibiotic prophylaxis. As the majority of our patients are more than 60 years old, we avoid the use of cephalosporins, as this can predispose toward pseudomembranous colitis [8]. Our patients receive metronidazole (500 mg IV), gentamicin (120 mg IV), and benzyl penicillin (1.2 g IV) with induction of anesthesia. We omit the penicillin if the patient is allergic. We see very few cases of chest infection in our group due to the use of regional anesthesia and active pre- and postoperative physiotherapy.

Thrombosis

Patients with gynecological cancer are at increased risk of thrombosis resulting from the malignancy and the effects of pelvic surgery. Many patients have had decreased mobility prior to surgery as a result of massive ascites. The ascites, combined with a pelvic mass, which can compress the venous return from the legs, causes the woman with gynecological cancer to present a special risk for thromboembolism. In addition, many women with gynecological cancer have a morbidly increased body mass index and thus are at risk of embolism. Following gynecological oncology surgery, the incidence of deep vein thrombosis without prophylaxis is in excess of 40% [9].

Therapeutically, a number of gynecological oncology patients are taking agents that lead to an increased risk of thromboembolism. While conventional hormone replacement therapy (HRT) is well known to predispose to thromboembolism, patients taking tamoxifen have a greater risk of thrombosis and are therefore advised to stop taking it 2 weeks before surgery. This point is important, as there is an increased number of breast cancer patients who opt for surgical ablation of their ovaries as part of their breast cancer management.

We use low-molecular-weight heparin (40 mg subcutaneously) on a daily basis. This regimen is given at 18:00 hours on admission and so will not interfere if an epidural is used the following morning. In addition, patients wear graduated stockings and are well hydrated. We prefer to use regional anesthesia in addition to the general anesthesia, as this has the positive benefifit of reducing thrombosis. Calf stimulation is also used in the operating theater, although the evidence for this procedure’s benefifit is not conclusive. We continue the low-molecular-weight heparin until the patient is discharged from the hospital.

In patients with signifificant deep vein thrombosis, we also consider using an inferior vena caval umbrella fifilter inserted under radiological control. Its use greatly reduces the risk of fatal pulmonary embolus, which is especially marked when there is bilateral iliac venous thrombosis associated with a pelvic mass.

Hemorrhage and Transfusion

During extensive surgery for advanced malignancy, patients are at signififi cant risk for intraoperative or primary blood loss. We routinely crossmatch 4 units of blood for patients undergoing ovarian cancer surgery. With patients undergoing interval debulking surgery, we often anticipate an anemia due to the cancer and the effect of chemotherapy. Patients will often be transfused as the operation starts. Our anesthetic team prefers this to transfusion on the day prior to the operation. As these patients are operated on in the window between cycles of chemotherapy, we do not delay the patient as one might do other patients with anemia for a benign operative indication. Secondary hemorrhage occurs rarely and is usually associated with a slipped ligature or unrecognized bleeding point. Often there is a large raw area following tumor resection, and we fifind that lavage with hot (30˚C–40˚C) water (not saline) allows identifification of bleeding points.

Unfortunately, we do not have easy access to erythropoietin for our chemotherapy patients in the NHS. This subcutaneous treatment can be useful to maintain the hemoglobin during chemotherapy and reduce the need for transfusion prior to interval debulking surgery.

Damage to Organs

Radical gynecological surgery aims to remove as much of the disease as required, including a margin of normal tissue. In cervical cancer surgery, this leads to Wertheim’s approach, whereby the ureter, bladder, and bowel are dissected free from the cervical cancer. The incidence of fifistula rate is reported as between 1% and 6% for this surgery. During lymphadenectomy, there is a risk of major vessel damage. Vascular injury associated with lymphadenec

2. Complications in Gynecological Oncology

tomy in endometrial cancer occurred in 0.7% of the cases; however, this was satisfactorily managed through adequate surgical training and experience of staff within the unit [10]. During ovarian surgery, the disease is usually con

ned to the peritoneal cavity, and signifificant removal of disease can be achieved by peritoneal stripping. Rectal resection with primary anastomosis for clearance of pelvic disease is advocated by some. The acceptable level for anastomotic leak should be equivalent to that for rectal surgery. In the cancer center, we have access to many specialists who can provide intraoperative advice regarding organ injury. This is very helpful when considering injuries, which fortunately are very rare.

Wound dehiscence and hernias are relatively uncommon but are associated with cancer cachexia and midline incisions.

Psychological Complications

The patient diagnosed with gynecological cancer often responds by wanting everything possible done to remove the cancer. While a postmenopausal woman, who has completed her reproductive life, may view a hysterectomy as the removal of an organ that has “turned bad,” a young woman may have a very different viewpoint. This is especially marked for those women whose diagnosis is made through screening. The woman diagnosed through screening has never had any symptom or sign of the disease and relies on the medical service for making the diagnosis as well as treating the cancer. The patient then has to live through the life-threatening illness, with major surgery and recovery, never having been “sick” in the fifirst place.

Although the majority of women with gynecological cancer have already completed their families or are postmenopausal, a small group of younger gynecological cancer patients still have fertility needs. This situation is also pertinent for those patients with breast cancer. Preservation of fertility potential can pose a signifificant problem. Germ cell ovarian cancer can be treated with conservative surgery, as this disease needs treatment with chemotherapy. Recognition of the potential of this condition is imperative, as germ cell ovarian cancer is associated with a young age group and an overall better survival rate. As there has been a tremendous increase in cervical intraepithelial neoplasia (CIN), a number of young women are requiring many cervical treatments. Excisional treatments to the cervix lead to earlier delivery. Consideration must be given to assisted fertility techniques for collection of oocytes or embryos for these young women, although there is often limited time for this treatment.

Radical vulval surgery is associated with severe changes to body image. This has prompted the move to the triple incision, with which we try to reduce the morbidity of the traditional radical en bloc vulvectomy. We aim to perform a wide local excision with a 2 cm macroscopically clear margin from the tumor. This reliably leaves an 8 mm pathologically clear margin, which is associated

with minimal risk of local recurrence. The inguino-femoral lymphadenectomy results in a signifificant risk of lymphedema, which is ugly and has its associated comorbidity. In the early postoperative period, wound healing is compromised by infection and/or formation of lymphocysts in 20%–30% of patients, while in the long term, lymphedema of the legs with increased risk for cellulitis is reported in 10%–70% of patients.

Sexual dysfunction has been measured in up to 80% of women undergoing gynecological cancer surgery [11].

How to Reduce Complications Further

Complications associated with gynecological cancer surgery can be reduced by addressing several areas of practice, starting with the patient and leading through aspects of the disease, operation, surgeon and his or her team, and therapy.

Through education, patients can be advised about disease-reduction activity. In gynecological cancer, this is the use of the oral contraceptive pill for 5 years, which leads to a 50% reduction in ovarian cancer risk, albeit with an increased risk of cervical cancer. The use of tamoxifen leads to a signifificant reduction in breast cancer, but its long-term usage is associated with a signififi cant increased risk of endometrial cancer. The move to the aromatase inhibitors for breast cancer will lead to much less endometrial disease. Uptake of appropriate screening methods that have been validated is important. We have seen a signifificant reduction in cervical cancer since the active call/recall system for cervical screening by primary care was introduced in 1988. Cervical cancer has become a rare cancer in the last decade in the United Kingdom, a situation that has not been mirrored in the rest of Western Europe. The role of laparoscopic prophylactic bilateral oophorectomy for patients at high risk of genetically carried ovarian cancer is important. The use of preadmission assessment is vital to allow the anesthetist to have access to the patient several weeks prior to the operation. The patient’s physical state can be optimized before surgery.

The approach to the disease can be modifified in several ways. The use of better imaging allows the surgeon to be fully aware of the extent of the disease. This may lead to anticipation of and preparation for bowel surgery by both the surgeon and the patient. It may modify the need to operate, as, if more extensive disease is discovered on imaging, we may consider radiotherapy for cervical cancer or neoadjuvant chemotherapy for patients with extensive ovarian cancer. The use of the “risk-of-malignancy index” [12] has been validated as a method to refer cases of ovarian cancer to a center where there is a survival advantage for the patient. We use a cutoff of 200 for the risk-ofmalignancy index and have found it to be very effective. Neoadjuvant chemotherapy may separate out those patients who are chemotherapeutically resistant, and therefore we operate only on those patients who have chemosensitive disease. This again allows for the patient’s condition to be optimized. With the effect of chemotherapy, the ascites disappears and the cachexia often improves. We have active input from dieticians, and patients who are having

2. Complications in Gynecological Oncology

diffificulties with nutrition are given early support, which may include parenteral nutrition for some.

Not operating is perhaps the best way of reducing operative complications. We screen our patients with postmenopausal bleeding with transvaginal ultrasound. Those patients with thin regular endometrium do not undergo any further investigation. This population amounts to more than 40% of the patient group, and we avoid the risk of operative intervention (relating to outpatient hysteroscopy) for these patients. The likelihood of a missed cancer is very small <<1%.>

The value of the multidisciplinary meeting cannot be overemphasized in the management of reducing complications. An important role in the meeting is that of the specialist pathologist, who provides information leading to either more or less extensive surgery. As well as informing the team about the surgery, the pathological opinion may advise with respect to the need for adjuvant therapy or observation alone without further therapy.

Laparoscopic surgery has not been used widely by oncology centers in the United Kingdom. Our experience is that for endometrial and cervical cancer, there are quite considerable benefifits for minimal-access techniques relating to diagnosis and recovery with no adverse effects.

Repair of the midline abdominal incision should use a mass-closure technique with a long-lasting absorbable or nonabsorbable looped suture. Less pain is associated with a long-lasting absorbable suture. Repair of incisional hernia is best achieved with mesh [14].

Having the right surgeon for the operation is very important. The success of the operation is better in centers with a higher frequency of procedure. Surgery in this setting allows the utilization of a surgeon whose is appropriately trained, another factor leading to better outcomes. Junor et al. [15] demonstrated that an operation for ovarian cancer performed by a gynecological oncologist was associated with a 25% better outcome for advanced disease

than an operation performed by the generalist; this translates into a signifificant survival advantage. This fifinding is in addition to the patient being managed by the multidisciplinary team and receiving the appropriate chemotherapy.

The use of psychosexual support usually via a specialist nurse who has access to additional expertise is very helpful in alleviating patients’ psychological distress.

Return to theater is a problem that occurs but is diffificult to quantify. Early return to theater for an appropriate reason can be life saving. It is essential, therefore, that the postoperative care for the patient is of high quality.

In the West Anglia Cancer Network, we are using videoconferencing, which allows for the interaction of the local unit–level team with the specialist multidisciplinary team at the center. This leads to better discussion and management for patients with cancer and precancer without requiring that patients or clinicians travel to the center.

Conclusion

Gynecological cancer surgery is associated with complications, some of which are avoidable by selecting the correct operation, surgeon, and hospital for the procedure. Other complications may be reduced by optimizing the patient’s condition before surgery and managing the patient in specialist units.

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