Low-dose heparin.

The use of small doses of subcutaneously administered heparin for the prevention of DVT and pulmonary embolism is the most widely studied of all prophylactic methods. More than 25 controlled trials have demonstrated that heparin given subcutaneously 2 hours preoperatively and every 8 to 12 hours postoperatively is effective in reducing the incidence of DVT. The value of low-dose heparin in preventing fatal pulmonary emboli was established by a randomized, controlled, multicenter international trial, which demonstrated a significant reduction in fatal postoperative pulmonary emboli in general surgery patients receiving low-dose heparin every 8 hours postoperatively. In gynecologic oncology patients, a randomized trial of heparin given either in a regimen of 5000 units subcutaneously 2 hours preoperatively and every 8 hours postoperatively or 5000 units subcutaneously every 8 hours preoperatively (a minimum of three preoperative doses) and every 8 hours postoperatively was performed. Both of these prophylaxis regimens were effective in significantly reducing the incidence of postoperative DVT in patients with gynecologic cancers. The authors conclude that in women undergoing surgery for gynecologic malignancy, a regimen of low-dose heparin 5000 units every 8 hours is necessary to provide effective prophylaxis.

The benefits of unfractionated heparin (UFH) are its rapid onset of action and ability for quick reversal; ability for frequent monitoring with activated partial thromboplastin time (aPTT) levels; and lack of renal metabolism, making it ideal in cases of renal insufficiency or renal failure. The most serious adverse risk of UFH use is the occurrence of heparin-induced thrombocytopenia (HIT). HIT has been found to be associated with low-dose heparin use in 6% of patients after gynecologic surgery, although its overall postoperative risk is considered to be around 1%. If patients remain on low-dose heparin for more than 4 days, it is reasonable to check a daily platelet count for 14 days or until heparin is stopped, whichever comes first. Low-dose heparin is also limited by a narrow therapeutic range, requiring frequent monitoring.

Low-molecular-weight heparins.

Low-molecular-weight heparins (LMWHs) are the preferred choice in perioperative pharmacologic prophylaxis. LMWHs are fragments of heparin that vary in size from 4500 to 6500 daltons. When compared with UFH, LMWHs have more anti-Xa and less antithrombin activity, leading to less effect on partial thromboplastin time (PTT) and possibly to fewer bleeding complications. An increased half-life of 4 hours results in increased bioavailability when compared with UFH. The increase in half-life of LMWHs also allows the convenience of once or twice-a-day dosing at 30 to 40 mg/day and can be used in the outpatient setting.

Randomized controlled trials (RCTs) have compared LMWH with UFH in patients undergoing gynecologic surgery. In all studies, there was a similar incidence of DVT. Bleeding complications were similar between the UFH and LMWH groups, and meta-analysis of all studies comparing the incidence of HIT confirmed that HIT is significantly less common with LMWH. A meta-analysis of general surgery and gynecologic surgery patients from 32 trials likewise indicated that daily LMWH administration is as effective as UFH in DVT prophylaxis without any difference in hemorrhagic complications, and these results have been confirmed in cancer surgery populations. Finally, prolonged prophylaxis for 4 weeks postoperatively has resulted in improved outcomes in high-risk surgical populations. In one randomized study of 1113 patients, 4 weeks of treatment after abdominal or pelvic cancer surgery reduced VTE rate from 4.6% to 0.8%, without increased bleeding complications. This extended prophylaxis has been adopted as the standard of care by the American College of Chest Physicians (ACCP), the National Comprehensive Cancer Network, and the American Society of Clinical Oncology.

Oral agents.

Investigations into the use of oral agents, specifically vitamin K antagonist warfarin, and a host of newly developed factor Xa inhibitors is ongoing. High-quality randomized trials and investigations in cancer populations have been limited to date, so the agents are not recommended in perioperative VTE prophylaxis at this time.

Graduated compression stockings.

Controlled studies of graduated pressure stockings are limited but do suggest modest benefit when they are carefully fitted. Poorly fitted stockings may be hazardous to some obese patients who develop a tourniquet effect at the knee or midthigh. Variations in human anatomy do not allow perfect fit of all patients to available stocking sizes. There is no therapeutic advantage of thigh-length stockings as compared with calf-length stocking. The simplicity of elastic stockings and the absence of significant side effects are probably the two most important reasons that they are often included in routine postoperative care.

External pneumatic compression.

The largest body of literature dealing with the reduction of postoperative venous stasis deals with intermittent external compression of the leg by pneumatically inflated sleeves placed around the calf or leg during intraoperative and postoperative periods. Calf compression during and after gynecologic surgery significantly reduces the incidence of DVT on a level similar to that of low-dose heparin. In addition to increasing venous flow and pulsatile emptying of the calf veins, external pneumatic compression (EPC) also appears to augment endogenous fibrinolysis, which may result in lysis of very early thrombi before they become clinically significant.

The duration of postoperative EPC has differed in various trials.

External pneumatic compression used in patients undergoing major surgery for gynecologic malignancy has been found to reduce the incidence of postoperative venous thromboembolic complications by nearly threefold but only if calf compression is applied intraoperatively and for the first 5 postoperative days. Patients with gynecologic malignancies may remain at risk because of stasis and hypercoagulable states for a longer period than general surgical patients and therefore appear to benefit from longer use of EPC.

External pneumatic leg compression has no significant side effects or risks and is considered slightly more cost effective compared with pharmacologic methods of prophylaxis. Of course, compliance to wearing the leg compression while in bed is of utmost importance, and the patient and nursing staff should be educated to the proper regimen for maximum benefit. We have investigated the risk factors associated with the failure of external compression to prevent DVT in a retrospective analysis of 1862 consecutive gynecologic surgery patients who received postoperative intermittent pneumatic compression. A history of prior VTE, diagnosis of cancer, and age older than 60 years were factors independently associated with the development of VTE despite EPC prophylaxis ( P <0.05). Patients having two or more of these factors had a 16-fold increased risk of postoperative VTE despite prophylaxis. In these extremely high-risk patients, of which the majority of gynecologic oncology patients would be categorized, combined methods of prophylaxis (eg, EPC plus low-dose UFH or LMWH) is recommended by the guidelines written by the ACCP. Although there have be no randomized trials on ECP alone versus combination prophylaxis specifically within gynecologic oncology populations, high-quality data from other cancer surgical populations have led to consensus recommendations that we follow. Mechanical prophylaxis alone should be reserved for perioperative gynecologic oncology patients with unacceptably high bleeding risk.

Diagnosis of deep vein thrombosis.

Because pulmonary embolism is the leading cause of death after gynecologic surgical procedures, identification of high-risk patients and the use of prophylactic VTE regimens is an essential part of management. In addition, the early recognition of DVT and pulmonary embolism and immediate treatment are critical. Most pulmonary emboli arise from the deep venous system of the leg, although after gynecologic surgery the pelvic veins are a known source of fatal pulmonary emboli also.

The signs and symptoms of DVT of the lower extremities include pain, edema, erythema, and prominent vascular pattern of the superficial veins. These signs and symptoms are relatively nonspecific; 50% to 80% of patients with these symptoms do not actually have DVT. Conversely, approximately 80% of patients with symptomatic pulmonary emboli have no signs or symptoms of thrombosis in the lower extremities. Because of the lack of specificity when signs and symptoms are recognized, additional diagnostic tests should be performed to establish the diagnosis of DVT.

Treatment of deep vein thrombosis.

The treatment of postoperative DVT requires the immediate institution of anticoagulant therapy. Untreated, symptomatic DVT is associated with a 50% risk of pulmonary embolism, and untreated pulmonary embolism carries a 30% risk of mortality. Treatment may be with either UFH or LMWHs followed by 6 months of oral or subcutaneous anticoagulant therapy. Prolonged anticoagulation (lifetime) is recommended for women who continue to have active cancer (ie, those not in remission after treatment) because they remain at very high risk to rethrombose.

Oral anticoagulants.

If oral anticoagulation must be used (eg, patient refuses daily injections, previous history of HIT), a vitamin K antagonist such as warfarin is preferred over no therapy. The conversion from parenteral heparin or LMWH to oral warfarin may start on the initial day of therapy. The change in INR resulting from warfarin administration often precedes the anticoagulant effect by approximately 2 days, during which time low protein C levels are associated with a transient hypercoagulable state. Therefore, both heparin and warfarin are given, and the heparin is discontinued when the warfarin has reached a therapeutic INR of 2 to 3 for 2 consecutive days. Patients should be cautioned to avoid the use of drugs and dietary products that might alter the metabolism or absorption of warfarin.

New agents such as direct thrombin or factor Xa inhibitors that have been approved for the treatment of acute DVT have not been well tested in cancer populations. Given the significant impact of surgery, chemotherapy, and radiation on a patient’s nutrition, performance status, and comorbid conditions, the authors do not believe there is sufficient data to support the use of the medications over warfarin. Their use is best restricted to scenarios when co-management with a hematologic specialists is available.

Diagnosis of pulmonary embolism.

Many of the signs and symptoms of pulmonary embolism are associated with other, more commonly occurring pulmonary complications after surgery. The classic findings of pleuritic chest pain, hemoptysis, shortness of breath, tachycardia, and tachypnea should alert the physician to the possibility of a pulmonary embolism. Many times, however, the signs are much more subtle and may be suggested only by a persistent tachycardia or a slight elevation in the respiratory rate. Several diagnostic algorithms have been devised to aid in estimating the likelihood of pulmonary embolism before definitive imaging, such as the Wells or Geneva scoring systems. Interestingly, these algorithms have been compared against physician clinical estimations in a meta-analysis of 52 studies including 55,268 patients. Clinical acumen indeed has comparable sensitivity (0.85 vs. 0.84–0.91) to structured diagnostic algorithms when both are combined with D-dimer testing. Patients with suspected pulmonary embolism can be evaluated initially by chest radiography, electrocardiography, and arterial blood gas assessment. However, a high clinical suspicion or high likelihood based on diagnostic algorithms should prompt immediate spiral CT scan of the chest for definitive diagnosis. Any evidence of abnormality should be further evaluated by spiral CT scan of the chest if renal function permits. Ventilation-perfusion lung scan is an option in the setting of renal insufficiency or failure, although, a high percentage of lung scans may be interpreted as “indeterminate.” In this setting, careful clinical evaluation and judgment are required to decide whether pulmonary arteriography should be obtained to document or exclude the presence of a pulmonary embolism.

The treatment of pulmonary embolism is similar to that of acute DVT in the hemodynamically stable patient. UFH, LMWH, or fondaparinux are all initial parental anticoagulation treatment options. Recommendations from the ACCP currently favor LMWH or fondaparinux for initial treatment, although UFH may be more prudent for the gynecologic oncology patient for whom a perioperative status or high disease burden often confers a bleeding risk requiring easy reversal of anticoagulation method. Hemodynamically unstable patients require immediate care in an intensive care unit (ICU) and assessment for thrombolytic therapy (eg, recombinant tissue type plasminogen activator, streptokinase) or embolectomy if thrombolysis is contraindicated.

Superior vena cava syndrome.

Superior vena cava syndrome is caused by advanced cancers arising in or invad­ing the mediastinum, subsequently obstructing the venous drainage of the head, neck, and upper thoracic regions. Primary tumors are most commonly the cause of this syndrome (bronchogenic carcinomas), although metastasis to the mediastinum from gynecologic cancers can also present in this manner. The vena cava has a low intravascular pressure and is easily compressed by adjacent masses. Most commonly, the symptoms caused by venous obstruction are dramatic swelling and plethora of the head, neck, upper extremities, and chest. Pleural and pericardial effusions can occur with decreased venous return to the heart and a resultant decrease in cardiac output. Patients also commonly complain of a severe headache. A similar clinical syndrome is also seen associated with thrombosis of the subclavian vein and superior vena cava, which is induced by central venous catheters. The diagnosis of the cause of superior vena cava syndrome is critical to selecting proper management. If a localized primary or metastatic neoplasm is identified, immediate radiation therapy is usually the most effective method to achieve resolution. Radiation therapy to the mediastinum in doses of 400 cGy for 3 days and then 150 to 180 cGy per day for a total dose of 3000 to 5000 cGy has been successful in relieving the vascular obstruction. Responses are commonly recognized in 3 to 4 days. Chemotherapy may also play a role, although the resolution of symptoms is usually much slower. Expandable wire stents across the constricted portion of the vena cava have also been used successfully.

In patients in whom thrombosis is the etiology of venous obstruction, immediate anticoagulant therapy should be instituted ( Fig. 16.3 ). The edema and plethora will usually diminish in 1 to 3 days. In many instances, the central venous catheter may be left in place and used. However, if the condition persists or recurs, the catheter should be removed.

Extensive thrombosis of large vessels in the thorax. Multiple collaterals are present. The subclavian catheter is evident (arrow) .

Intraoperative management of vascular complications.

Surgery for gynecologic cancer often requires extensive dissection in the retroperitoneal space, which may be distorted by cancer metastatic to lymph nodes or invading adjacent structures. It is not surprising, then, that injury to pelvic veins and arteries is common and may result in significant intraoperative blood loss and hemorrhage. Surgeons must be prepared for this eventuality and have in their armamentarium the tools and skills to bring a stop to the bleeding.

Before attempting to bring final control to a significant bleeding area, a few basic principles should be used. First, the patient’s blood volume and coagulation factors must be maintained at all times. Poor communication between the surgeon and the anesthesiologist can lead to significant hypovolemia and cardiovascular instability. Frequent serial laboratory assessments are critical in this setting. Loss of coagulation factors during intraoperative hemorrhage results in continued bleeding that cannot be controlled by surgical means. The surgeon should pack the involved area to allow replacement of blood volume (PRBCs), coagulation factors (FFP, platelets, and cryoprecipitate), and acquisition of appropriate assistance. When the patient is stable and the team is fully prepared, the packed area should be exposed a small area at a time to identify the specific bleeding site.

Before attempting to control the bleeding point, the adjacent anatomy should be identified and protected. In particular, the ureter, adjacent vessels, and viscera must be recognized to avoid further injury. In most cases of arterial bleeding, the artery can be isolated and controlled with sutures. Small arteries may be best controlled by vascular clips, but larger arteries may require sutures with 4-0 or 5-0 vascular suture (Prolene). This holds for injury to the aorta and common and external iliac arteries. Injury to the internal iliac (hypogastric) artery may be controlled with total ligation of the artery. Patency of distal arteries should be confirmed throughout the remainder of the procedure and postoperatively. In rare instances, arterial injuries must be managed by vascular grafting.

Venous bleeding in the pelvis is probably more common given the fragility of the thin vein wall and the extensive network of pelvic venous plexus. Often a specific bleeding point cannot be identified but, after several minutes of direct pressure on the bleeding area, a clot will form over the low-pressure veins, and the bleeding will resolve. If it does not, control will have to be achieved with vascular clips, clamps, and suture ligature. Slow but persistent oozing from unidentified vessels can often be controlled by products that either serve as a matrix for clotting (Avitene, Surgicel, Gelfoam) or supply clotting factors that complete the clotting cascade (CoSeal, TISSEEL, FLOSEAL). After application of any of these products, pressure should be applied to the site for 5 minutes and then the site should be reevaluated. If bleeding has not been controlled, it may be necessary to place a pack and transfer the patient to an ICU. In all cases, it should be emphasized that prompt replacement of clotting factors provided by transfusion of FFP and platelets is critical to achieve hemostasis in the face of hemorrhage.

Replacement of platelets and clotting factors in patients with massive transfusion and microvascular bleeding is dependent on clinical and surgical assessments. Guidelines have been provided by the American Society of Anesthesiologists task force regarding replacement of these products. In general, platelet transfusion is rarely indicated for counts greater than 100,000/µL and usually indicated for counts less than 50,000/µL (with intermediate platelet counts 50,000/µL to 100,000/µL, transfusion should be based on the risk of bleeding). FFP therapy is indicated in massively transfused patients with microvascular bleeding or hemorrhage if the prothrombin time (PT) or aPTT values exceed 1.5 times the normal values. In cases of massive intraoperative blood loss, it may be prudent to administer FFP empirically. This strategy is aimed at preventing the patient from becoming hypocoagulable while awaiting the laboratory results (PT and PTT), which may take nearly an hour and another hour to thaw the FFP before it is available to be administered. Cryoprecipitate transfusions are recommended for correction of microvascular bleeding in massively transfused patients with fibrinogen concentrations less than 80 to 100 mg/dL. For trauma patients with massive blood loss, on the order of 30% to 40% of their blood volume, a transfusion ratio of 1 : 1 : 1 for PRBCs, FFP, and platelets has been consistently reported to be associated with decrease in death caused by hemorrhage. If surgical bleeding has taken on this level of severity, such a massive transfusion protocol should be initiated.

Bleeding from the sacrum is usually not encountered except in the course of performing a total pelvic exenteration or rectosigmoid resection or during a sacral-colpopexy. If bleeding from the sacrum cannot be controlled by suture ligatures or vascular clips, placement of sterile thumbtacks pushed into the sacral bone will usually compress veins exiting the sacrum and achieve hemostasis.

Hypogastric (internal iliac) artery ligation.

When the usual steps to control hemorrhage have failed, hypogastric artery ligation should be performed. Although the arterial blood supply to the pelvis is rich with anastomosis, ligation of the hypogastric arteries will usually decrease the arterial and venous pressure to the point at which (in a patient who is not hypocoagulable) venous bleeding will slow and can either be controlled by ligature or will clot with prolonged packing.

To safely perform hypogastric artery ligation, the vascular anatomy must be exposed, and adjacent structures, especially the ureter, must be identified. A retroperitoneal approach should be taken. The peritoneum overlying the psoas muscle (lateral to the external iliac artery) should be incised parallel to the artery. As the peritoneum is mobilized medially, the external iliac artery will first be identified. Dissection cephalad along the external iliac artery will identify the common iliac artery and the bifurcation of the internal iliac artery. Invariably, the ureter crosses the pelvic brim at the bifurcation of the common iliac artery. At this location, the ureter will be identified attached to the medial peritoneum. Further opening of the retroperitoneal space keeping the iliac vessels lateral and the ureter medial will create the pararectal space and further expose the internal iliac artery. Be aware that the common external and internal iliac veins lie just beneath their respective arteries. Without clear identification of these veins, injury can occur, which will further complicate the procedure. The hypogastric artery bifurcates into an anterior and posterior branch 2 to 3 cm from its origin from the common iliac artery. Because most bleeding arises from the blood supply from the anterior division, the anterior branch should be ligated if at all possible. (Ligation of the posterior branch increases the risk of buttock pain and potential necrosis of the gluteus.) A right angle clamp should be carefully passed from lateral to medial beneath the hypogastric artery. A heavy suture (eg, 0-silk) should be used to ligate the artery ( Fig. 16.4 ). There is no reason to transect the artery between two ligatures. It is usually best to perform bilateral hypogastric artery ligation as the collateral blood supply crosses over the midline.

Technique for intraoperative ligation of the hypogastric artery. The ligature is placed 2 to 3 cm below the bifurcation so that the posterior branch will not be ligated. The clamp is passed lateral to medial to prevent trauma to the internal iliac vein.

(From Nichols DH, Clarke-Pearson DL, eds. Gynecologic, Obstetric and Related Surgery , 2nd ed. St. Louis, 2000, Mosby.)

Finally, if all methods to control hemorrhage have been unsuccessful, the bleeding site should be packed firmly, and the abdomen should be closed. The patient should be taken to the surgical ICU and stabilized. Central monitoring and blood product replacement should be the primary focus of management. After the patient is stabilized, attempts at angiographic embolization should be considered. Ultimately, after 24 to 48 hours, the patient should be returned to the operating room and reexplored and the pack removed carefully. Surprisingly, many times the bleeding will have stopped as a result of compression of the injured veins and correction of the hypocoagulable state.

Management of shock.

During and after gynecologic surgery, blood-volume deficit that results from intraoperative blood loss or postoperative hemorrhage is the most common cause of shock. This shock usually is manifested by arterial hypotension, tachycardia, a weak pulse, anxiety, skin pallor, diminished urinary output, and peripheral vasoconstriction. In addition to hemorrhage (hypovolemic shock), the differential diagnosis of shock must include many other causes, such as cardiogenic (myocardial infarction) and cardiac compressive conditions (cardiac tamponade or pneumothorax), sepsis, drug overdose, and pulmonary embolism. Appropriate studies are dictated by the patient’s signs and symptoms.

Consideration should be given to obtaining arterial blood gas analysis, an electrocardiogram, a chest radiograph, blood chemistry studies, and blood cultures. The patient should be prepared for blood transfusion. The degree and duration of postoperative shock determine the need for resuscitation, central venous pressure monitoring, and Swan-Ganz pulmonary artery catheterization.

Resuscitation of a hemorrhaging patient during or after gynecologic surgery involves stabilization of the hemodynamic status and correction of the cause of the blood loss. When the hemorrhage is massive, fluid, electrolyte, and hemodynamic shifts are likewise massive. Central to stabilization efforts are the replacement and maintenance of adequate intravascular volume.

Central monitoring.

Invasive cardiovascular monitoring may be lifesaving for patients with massive hemorrhage or patients who are at additional risk because of preexisting cardiopulmonary disorders. The monitoring allows the rational use of fluids and cardioactive medications while avoiding their complications.

In patients with marked hemodynamic instability, peripheral artery cannulation allows continuous monitoring of systemic arterial pressure and ready access to obtain repeated analysis of arterial blood gases. The radial artery is usually chosen because of accessibility and has good collateral circulation, although the brachial and femoral arteries may be used. The complications of arterial cannulation include catheter-related septicemia (4% in one large study), local infection (as high as 18%), and arterial embolization (0.2%–0.6%).

In patients without cardiopulmonary disease, monitoring of central venous pressure along with monitoring of the vital signs, urine output, and other clinical signs usually provide sufficient information for appropriate fluid resuscitation. In addition, central venous pressure monitoring avoids several of the complications of a pulmonary artery (Swan-Ganz) catheter.

A central venous catheter may be introduced into the great intrathoracic veins by way of the antecubital, external or internal jugular, or subclavian veins. Cannulation of the right internal jugular vein, which provides a straight course to the right atrium, has the lowest overall complication rate. In all cases, a chest radiograph should be obtained immediately after catheter insertion to confirm proper location and to assess for possible pneumothorax.

The usefulness of the Swan-Ganz catheter in critically ill patients (even those without heart disease) who do not respond to therapy based on an initial noninvasive assessment is primarily limited to its use as a diagnostic monitoring tool. Several randomized trials, including those of high-risk surgical patients, have confirmed that there is no mortality benefit to use of the Swan-Ganz catheter. It does provide additional diagnostic information concerning unsuspected cardiac dysfunction, pulmonary artery embolization, or sepsis. Patients without primary myocardial insult but with hypotension and evidence of inadequate perfusion of vital organs (eg, oliguria, acidosis, mental obtundation) can be managed with more information ( Table 16.2 ).

In patients with cardiac or pulmonary disease, cardiac output and resistance measurements allow the proper use of pressors, afterload and preload reducers, and fluids. In addition, if sepsis is part of the clinical picture, careful monitoring of pulmonary capillary wedge pressures may be necessary to prevent pulmonary edema, which is seen with even mild increases in left atrial pressures as a result of the increased permeability of the pulmonary vascular bed. This increased permeability also may be seen in patients in hypovolemic shock, again leading to pulmonary edema at relatively normal wedge pressures. Finally, invasive monitoring not only provides a direct measurement of cardiac function but also provides information within minutes about the effects of therapy.

These catheters may be placed from the antecubital fossa, although the percutaneous subclavian or internal or external jugular vein approaches are more commonly used. Complications of pulmonary artery catheters include pulmonary infarction distal to the catheter (1%–2% of cases), pulmonary artery rupture (0.2% of cases), balloon rupture (3% of cases), and sepsis (2% of cases), all of which are made more likely by prolonged use of the catheter.

Ileus.

After abdominal or pelvic surgery, most patients experience some degree of intestinal ileus. The exact mechanism by which this arrest and disorganization of GI motility occurs is unknown, but it appears to be associated with the opening of the peritoneal cavity and is aggravated by manipulation of the intestinal tract and prolonged surgical procedures. (Ileus is much less commonly associated with minimally invasive surgical procedures. If ileus were to occur after laparoscopy or robotic surgery, the surgeon should strongly consider a more serious bowel injury and evaluate the patient accordingly.) Infection, peritonitis, postoperative hypervolemia causing bowel wall edema, and electrolyte disturbances may also result in ileus. For most patients undergoing gynecologic cancer operations, the degree of ileus is minimal and GI function returns relatively rapidly, allowing the resumption of oral intake within a few days of surgery. Patients who have persistently diminished bowel sounds, abdominal distention, and nausea and vomiting require further evaluation and more aggressive management.

Ileus is usually manifest by abdominal distention and should be evaluated initially by physical examination assessing the quality of bowel sounds and searching for tenderness or rebound on palpation. The possibility that the patient’s signs and symptoms may be associated with a more serious intestinal obstruction or other intestinal complication must be considered. Pelvic examination should be performed to evaluate the possibility of a pelvic abscess or hematoma that may contribute to the ileus. Abdominal radiography to evaluate the abdomen in the supine position and in the upright position usually will aid in the diagnosis of an ileus. The most common radiographic findings include dilated loops of small and large bowel and air–fluid levels in the upright position. In postoperative patients, especially in the upright position, the flat plate of the abdomen may also show evidence of free air. This is a common finding after surgery; it lasts 7 to 10 days in some instances and is not indicative of a perforated viscus in most patients. The remote possibility of distal colonic obstruction or pseudoobstruction (Ogilvie syndrome) suggested by a dilated cecum should be excluded by rectal examination, proctosigmoidoscopy, or barium enema.

The initial management of a postoperative ileus is aimed at GI tract decompression and maintenance of appropriate IV replacement fluids and electrolytes.

• 1.
  

  If a patient has moderate to severe vomiting, not improved with bowel rest and antiemetics, an NG tube should be placed to evacuate the stomach of its fluid and gaseous contents. Prolonged NG suction continues to remove swallowed air, which is the most common source of air in the small bowel.

  
  
• 2.
  

  Fluid and electrolyte replacement must be adequate to keep the patient well perfused. Significant amounts of third-space fluid loss occur in the bowel wall, the bowel lumen, and the peritoneal cavity during the acute episode. GI fluid losses from the stomach may also lead to a metabolic alkalosis and depletion of other electrolytes. Careful monitoring of serum chemistries and appropriate replacement are necessary.

  
  
• 3.
  

  Most cases of severe ileus begin to improve over a period of several days. In general, this is recognized by reduction in the abdominal distention, return of normal bowel sounds, and passage of flatus or stool. Follow-up abdominal radiographs should be obtained as necessary for further monitoring.

  
  
  
  
  • •
    

    When the GI tract function appears to have returned to normal, the NG tube may be removed, and a liquid diet may be instituted.

    
    
  • •
    

    If a patient shows no evidence of improvement during the first 48 to 72 hours of medical management, other causes of ileus should be sought. Such cases may include ureteral injury, peritonitis from pelvic infection, unrecognized GI tract injury with peritoneal spill, or fluid and electrolyte abnormalities such as hypokalemia. In the evaluation of persistent ileus, the use of water-soluble upper GI contrast studies may assist in the resolution of the ileus, the recognition of a small bowel obstruction, or injury (leak) of the GI tract.

  
  

Small bowel obstruction.

Obstruction of the small bowel after abdominal surgery occurs in approximately 1% to 2% of patients, but it may be more common after radical gynecologic oncology procedures as a result of the extensive dissection and manipulation of the small bowel. (Again, this complication is less common in patients who have undergone minimally invasive surgery.) The most common cause of small bowel obstruction is adhesions to the operative site. If the small bowel becomes adherent in a twisted position, partial or complete obstruction may result from distention, ileus, or bowel wall edema. Less common causes of postoperative small bowel obstruction include entrapment of the small bowel into an incisional hernia and an unrecognized defect in the small bowel or large bowel mesentery. Early in its clinical course, a postoperative small bowel obstruction may exhibit signs and symptoms identical to those of ileus. Initial conservative management as outlined for the treatment of ileus is appropriate. Because of the potential for mesenteric vascular occlusion and resulting ischemia or perforation, worsening symptoms of abdominal pain, progressive distention, fever, leukocytosis, or acidosis should be evaluated carefully because immediate surgery may be required.

However, in most cases of postoperative small bowel obstruction, the obstruction is only partial, and the problem usually resolves with conservative management.

• 
  
  
  
  
  
  • 
    
    
    
    
    
    • 
      
      
      
      
      
      • •
        

        After several days of conservative management (NG tube drainage, fluid and electrolyte replacement), further investigation may be necessary. Evaluation of the GI tract with barium enema and an upper GI series with small bowel follow-through is appropriate. Alternatively, an abdominal and pelvic CT scan with GI contrast may be useful in identifying the location of obstruction (“transition point”) and evaluates for the presence of an abscess, lymphocele, or ureteral injury. In most cases, complete obstruction is not documented, although a narrowing or tethering of the segment of small bowel may indicate the site of the problem.

        
        
      • •
        

        Further conservative management with NG decompression and IV fluid replacement may allow time for bowel wall edema or torsion of the mesentery to resolve.

        
        
      • •
        

        If resolution is prolonged and the patient’s nutritional status is marginal, the use of TPN may be necessary.

      
      

    
    
    
    
  • 4.
    

    Conservative medical management of postoperative small bowel obstruction usually results in complete resolution. However, if persistent evidence of small bowel obstruction remains after full evaluation and an adequate trial of medical management, exploratory laparotomy may be necessary to surgically evaluate and manage the obstruction. In most cases, lysis of adhesions is all that is required, although a segment of small bowel that is badly damaged or extensively sclerosed from adhesions may require resection and reanastomosis.

  
  

Colonic obstruction.

Postoperative colonic obstruction after gynecologic oncology surgery is exceedingly rare. Advanced ovarian carcinoma is the most common cause of colonic obstruction in postoperative gynecologic surgery patients and is caused by extrinsic impingement on the colon by the pelvic malignancy. Occult intrinsic colonic lesions (eg, colon cancer) also may cause obstruction. When colonic obstruction is manifest by abdominal distention and abdominal radiographs reveal a dilated colon and enlarging cecum, further evaluation of the large bowel is required by barium enema or colonoscopy. Dilation of the cecum to more than 10 cm to 12 cm in diameter as viewed by abdominal radiography requires immediate evaluation because there is a higher probability of colonic perforation. When there is no logical cause for a mechanical obstruction, Ogilvie syndrome should be considered. Colon­oscopy should be performed, and the colonic gas should be evacuated. If a true mechanical obstruction is documented, surgical decompression by performing a colectomy, colostomy, or cecostomy may be required on an urgent basis. In some circumstances, an intraluminal stent may be placed endoscopically. Surgery should be performed as soon as the obstruc­tion is documented. Conservative management of colonic obstruction is not appropriate because the complication of colonic perforation has an exceedingly high mortality rate.

Diarrhea.

Episodes of diarrhea often occur after abdominal and pelvic surgery as the GI tract returns to its normal function and motility. However, prolonged and multiple episodes may represent a pathologic process such as impending small bowel obstruction, colonic obstruction, or pseudomembranous colitis. Excessive amounts of diarrhea should be evaluated by abdominal radiographs and stool samples tested for the presence of ova and parasites, bacterial culture, and Clostridium difficile toxin. Proctoscopy and colonoscopy may also be advisable in severe cases. Evidence of intestinal obstruction should be managed as outlined previously. Infectious causes of diarrhea should be managed with the appropriate antibiotics and fluid and electrolyte replacement. C. difficile –associated pseudomembranous colitis may result from recent exposure to any antibiotic. Discontinuation of these antibiotics (unless they are needed for another severe infection) is advisable, along with the institution of appropriate therapy. Because of the expense of vancomycin, the authors usually institute therapy with oral metronidazole for mild to moderate cases. Because of rising resistance to oral metronidazole, initiation of treatment with oral vancomycin may be necessary because clinical success (resolution of diarrhea) is lower (73% vs. 81%; P = 0.02) with metronidazole. Therapy should be continued until the diarrhea abates, and several weeks of oral therapy may be required to obtain complete resolution of the pseudomembranous colitis.

Fistula.

Gastrointestinal fistulas are relatively rare after gynecologic surgery. They are most often associated with malignancy, prior radiation therapy, or surgical injury to the large or small bowel that was unrecognized or a leak from an anastomosis. Signs and symptoms of GI fistula are often similar to those of small bowel obstruction or ileus except that a fever is usually a more prominent component of the patient’s symptoms. When fever is associated with GI dysfunction postoperatively, evaluation should include early assessment of the GI tract for its continuity. When fistula is suspected, the use of water-soluble GI contrast material is advised to avoid the complication of barium peritonitis. Evaluation with abdominal pelvic CT scan may also assist in identification of a fistula and associated abscess. Recognition of an intraperitoneal GI leak or fistula formation usually requires immediate surgery unless the fistula has drained spontaneously through the abdominal wall or vaginal cuff.

An enterocutaneous fistula arising from the small bowel and draining spontaneously through the abdominal incision may be managed successfully with medical therapy. Therapy should include NG decompression, replacement of IV fluids, TPN, and appropriate antibiotics to treat an associated mixed bacterial infection. If the infection is under control and there are no other signs of peritonitis, the surgeon may consider allowing potential resolution of the fistula over a period of up to 6 weeks. Some authors have suggested the use of somatostatin to decrease intestinal tract secretion and allow earlier healing of the fistula. In many cases, especially if the bowel was not radiated, the fistula will close spontaneously with this mode of management. If the enterocutaneous fistula does not close with conservative medical management, surgical correction with resection, bypass, or reanastomosis will be necessary in most cases.

A rectovaginal fistula that occurs after gynecologic surgery is usually the result of surgical trauma that may have been aggravated by the presence of extensive adhesions or tumor involvement of the rectosigmoid colon and cul de sac. Low rectal anastomoses are also at risk to breakdown and lead to a rectovaginal fistula. Perforation of a colonic diverticulum is another possible cause for a colovaginal fistula. A small rectovaginal fistula may be managed with a conservative medical approach in the hope that decreasing the fecal stream will allow closure of the fistula. A small fistula that allows continence except for an occasional leak of flatus may be managed conservatively until the inflammatory process in the pelvis resolves. At that point, usually several months later, correction of the fistula is appropriate. Larger rectovaginal fistulas that have no hope of closing spontaneously are best managed by performing an initial diverting colostomy followed by repair of the fistula after inflammation has resolved. After the fistula closure is healed and deemed successful, the colostomy may be taken down and closed.

Urinary tract infections.

Historically, the urinary tract has been the most common site of infection in surgical patients. However, the incidence reported in the more recent gynecologic literature has been less than 4%. This decrease in UTIs is most likely the result of increased perioperative use of prophylactic antibiotics.

Symptoms of a UTI may include urinary frequency, urgency, and dysuria. In patients with pyelonephritis, other symptoms include flank pain, headache, malaise, nausea, and vomiting. A UTI is diagnosed on the basis of microbiology and has been defined as the growth of 10 ⁵ organisms/mL urine cultured. Most infections are caused by coliform bacteria, with Escherichia coli being the most common pathogen. Other pathogens include Klebsiella , Proteus , and Enterobacter spp. Staphylococcus organisms are the causative bacteria in fewer than 10% of cases.

Despite the high incidence of UTIs in the postoperative period, few of these infections are serious. Most are confined to the lower urinary tract, and pyelonephritis is a rare complication. Catheterization of the urinary tract, either intermittently or continuously with the use of an indwelling catheter, has been implicated as a main cause of urinary tract contamination.

The treatment of UTI includes hydration and antibiotic therapy. Commonly prescribed and effective antibiotics include sulfonamide, cephalosporins, fluoroquinolones, and nitrofurantoin. The choice of antibiotic should be based on knowledge of the susceptibility of organisms cultured at a particular institution. In some institutions, for example, more than 40% of E. coli strains are resistant to ampicillin. For uncomplicated UTIs, an antibiotic that has good activity against E. coli should be given in the interim while awaiting the urine culture and sensitivity data.

Patients who have a history of recurrent UTIs, those with chronic indwelling catheters (Foley catheters or ureteral stents), and those who have urinary conduits should be treated with antibiotics that will be effective against the less common urinary pathogens such as Klebsiella and Pseudomonas spp . Chronic use of the fluoroquinolones for prophylaxis is not advised because these agents are notorious for inducing antibiotic-resistant strains of bacteria.

Pulmonary infections.

The respiratory tract is a relatively common site for complications after surgery for gynecologic cancer. Risk factors include extensive or prolonged atelecta­sis, preexistent chronic obstructive pulmonary disease, severe or debilitating illness, central neurologic disease causing an inability to clear oropharyngeal secretions effectively, and NG suction. In surgical patients, early ambulation and aggressive management of atelectasis are the most important preventive measures.

A significant proportion (40%–50%) of hospital-acquired pneumonias are caused by Gram-negative organisms. These organisms gain access to the respiratory tract from the oral pharynx. Gram-negative colonization of the oral pharynx has been shown to be increased in patients in acute care facilities and has been associated with the presence of NG tubes, preexisting respiratory disease, mechanical ventilation, tracheal intubation, and paralytic ileus (which is associated with microbial overgrowth in the stomach).

A thorough lung examination should be included in the assessment of all febrile surgical patients. In the absence of significant lung findings, chest radiography should nonetheless be obtained in patients at high risk for pulmonary complications. A sputum sample should also be obtained for Gram stain and culture. The treatment should include postural drainage, aggressive pulmonary toilet, and antibiotics. The antibiotic chosen should be effective against both Gram-positive and Gram-negative organisms, and in patients who are receiving assisted ventilation, the antibiotic spectrum should include drugs that are active against Pseudomonas organisms.

Wound infections.

The results of a prospective study of more than 62,000 wounds are revealing in regard to the epidemiology of wound infections. The wound infection rate varied markedly, depending on the extent of contamination of the surgical field. The wound infection rate for clean surgical cases (infection not present in the surgical field, no break in aseptic technique, no viscus entered) was lower than 2%, but the incidence of wound infections with dirty, infected cases was 40% or higher. Preoperative showers with hexachlorophene slightly lowered the infection rate for clean wounds, but preoperative shaving of the wound site with a razor (but not clippers) increased the infection rate. A 5-minute wound preparation immediately before surgery was as effective as preparation 10 minutes before surgery. The wound infection rate increased with the duration of the preoperative hospital stay and with the duration of the surgical procedure. (Prophylactic antibiotics should be readministered if the surgical procedure lasts longer than 4 hours.) In addition, incidental appendectomy increased the risk of wound infection in patients undergoing clean surgical procedures. The study concluded that the incidence of wound infections could be decreased by short preoperative hospital stays, hexachlorophene showers before surgery, clipping hair (not shaving) of the wound site immediately before incision, use of meticulous surgical technique, decreasing operative time as much as possible, bringing drains out through sites other than the wound, and dissemination of information to surgeons regarding their wound infection rates. A program instituting these conclusions led to a fall in the clean wound infection rate from 2.5% to 0.6% over an 8-year period. Although the wound infection rate in most gynecologic services has been lower than 5%, reflective of the “clean” nature of most gynecologic operations, it is higher in gynecologic oncology patients.

The symptoms of wound infection often occur late in the postoperative period, usually after the fourth postoperative day, and may include the presence of fever, erythema, tenderness, induration, and purulent wound drainage. Wound infections that occur on postoperative days 1 through 3 are generally caused by streptococcal and clostridial infections. The management of wound infections is mostly mechanical and involves opening the infected portion of the wound above the fascia, with cleansing and débridement of the wound edges as necessary. Wound care, consisting of débridement and dressing changes two to three times daily with mesh gauze, will promote growth of granulation tissue, with gradual filling in of the wound defect by secondary intention. The application of a Wound-Vac (negative pressure wound therapy) to larger wounds speeds recovery and minimizes dressing changes. In a gynecologic oncology population, the median number of days of wound vac therapy was 32 days (range, 3–88 days) with a 96% reduction in the median size of the wounds. Clean, granulating wounds can often be secondarily closed with good success, shortening the time required for complete wound healing.

The technique of delayed primary wound closure can be used in contaminated surgical cases to reduce the incidence of wound infection. Briefly, this technique involves leaving the wound open above the fascia at the time of the initial surgical procedure. Vertical interrupted mattress sutures though the skin and subcutaneous layers are placed 3 cm apart but are not tied. Wound care is instituted immediately after surgery and continued until the wound is noted to be granulating well. Sutures may then be tied, and the skin edges can be further approximated using sutures or staples. Using this technique of delayed primary wound closure, the overall wound infection rate has been shown to be decreased from 23% to 2.1% in high-risk patients.

Vaginal cuff infection after hysterectomy is characterized by erythema, induration, and tenderness at the vaginal cuff. Occasionally, a purulent discharge from the apex of the vagina may also be present. The cellulitis is often self-limited and does not require any treatment. Fever, leukocytosis, and pain localized to the pelvis may accompany severe cuff cellulitis and most often signifies extension of the cellulitis to adjacent pelvic tissues. In such cases, broad-spectrum antibiotic therapy should be instituted with coverage for Gram-negative, Gram-positive, and anaerobic organisms. If purulence at the vaginal cuff is excessive or if there is a fluctuant mass noted at the vaginal cuff, the vaginal cuff should be gently probed and opened with a blunt instrument. The cuff can then be left open for dependent drainage.

Intraabdominal and pelvic abscess.

The development of an abscess in the surgical field or elsewhere in the abdominal cavity is most likely to occur in contaminated cases in which the surgical site is not adequately drained or as a secondary complication of hematoma that becomes infected. The causative pathogens in patients who have intraabdominal abscess are usually polymicrobial in nature. The aerobes most commonly identified include E. coli and Klebsiella, Streptococcus, Proteus, and Enterobacter spp. Anaerobic isolates are also common, usually from the Bacteroides group. These pathogens are mainly from the vagina but also can be derived from the GI tract, particularly when the colon has been entered at the time of surgery.

An intraabdominal abscess is sometimes difficult to diagnose. The evolving clinical picture is often one of persistent febrile episodes with a rising white blood cell count. Findings on abdominal examination may be equivocal. If an abscess is located deep in the pelvis, it may be palpable by pelvic or rectal examination. For abscesses above the pelvis, diagnosis will depend on radiologic confirmation.

Ultrasonography can occasionally delineate fluid collections in the upper abdomen and the pelvis. However, bowel gas interference makes visualization of fluid collections or abscesses in the mid-abdomen difficult to distinguish. CT scanning with oral and IV contrast is much more sensitive and specific for diagnosing intraabdominal abscesses and is the radiologic procedure of choice.

Standard therapy for an intraabdominal abscess is drainage combined with appropriate parenteral administration of antibiotics. Abscesses located low in the pelvis, particularly in the area of the vaginal cuff, can often be reached through a vaginal approach. In many patients, the ability to drain an abscess by placement of a drain percutaneously under CT guidance has obviated the need for surgical exploration. With CT guidance, a pigtail catheter is placed into an abscess cavity via percutaneous, transperineal, transrectal, or transvaginal approaches. The catheter is left in place and irrigated daily until drainage decreases. Transperineal and transrectal drainage of deep pelvic abscesses has been successful in 90% to 93% of patients, obvi­ating the need for surgical management. However, for patients in whom radiologic drainage is not successful, surgical exploration and evacuation are indicated. The gold standard of initial antibiotic therapy has been the combination of ampicillin, gentamycin, and clindamycin. Adequate treatment can also be achieved with currently available broad-spectrum single agents (including the broad-spectrum penicillin), second- and third-generation cephalosporins, levofloxacin and metronidazole, and the sulbactam/clavulanic acid–containing preparations.

Necrotizing fasciitis.

Necrotizing fasciitis is an uncommon infectious disorder; approximately 1000 cases occur annually in the United States. The disorder is characterized by a rapidly progressive bacterial infection involving the subcutaneous tissues and fascia while characteristically sparing underlying muscle. Systemic toxicity is a common feature of this disease, as manifested by the presence of dehydration, septic shock, dis­seminated intravascular coagulation, and multiorgan system failure.

The pathogenesis of necrotizing fasciitis involves a polymicrobial infection of the dermis and subcutaneous tissue. Historically, hemolytic streptococcus was believed to be the primary pathogen responsible for necrotizing fasciitis. However, it is now evident that numerous other organisms are present in addition to streptococcus, including other Gram-positive organisms, coliforms, and anaerobes. Bacterial enzymes such as hyaluronidase and lipase released in the subcutaneous space destroy the fascia and adipose tissue and induce a liquefactive necrosis. In addition, noninflammatory intravascular coagulation or thrombosis subsequently occurs. Intravascular coagu­lation results in ischemia and necrosis of the subcutaneous tissues and skin. Late in the course of the infection, destruction of the superficial nerves produces anesthesia in the involved skin. The release of bacteria and bacterial toxins into the systemic circulation results in septic shock, acid–base disturbances, and multiorgan impairment.

The diagnostic criteria for necrotizing fasciitis include extensive necrosis of the superficial fascia and subcutaneous tissue with peripheral undermining of the normal skin, a moderate to severe systemic toxic reaction, the absence of muscle involvement, the absence of clostridia in wound and blood culture, the absence of major vascular occlusion, intensive leukocytic infiltration, and necrosis of subcutaneous tissue.

Most patients with necrotizing fasciitis suffer pain, which in the early stages of the disease is often disproportionately greater than that expected from the degree of cellulitis present. Late in the course of the infection, the involved skin may actually be anesthetized secondary to necrosis of superficial nerves. Temperature abnormalities, both hyperthermia and hypothermia, are concomitant with the release of bacterial toxins and with bacterial sepsis, which is present in up to 40% of patients. The involved skin is initially tender, erythematous, and warm. Edema develops, and the erythema spreads diffusely, fading into normal skin, characteristically without distinct margins or induration. Subcutaneous microvascular thrombosis induces ischemia in the skin, which becomes cyanotic and blistered. As necrosis progresses, the skin becomes gangrenous and may slough spontaneously. Most patients will have leukocytosis and acid–base abnormalities. Finally, subcutaneous gas may develop, which can be identified by palpation (crepitus) and by radiograph. The finding of subcutaneous gas by radiograph is often indicative of clostridial infection, although it is not a specific finding and may be caused by other organisms. These organisms include Enterobacter spp. , Pseudomonas spp. , anaerobic streptococci, and Bacteroides spp., which, unlike clostridial infections, spare the muscles underlying the affected area. A tissue biopsy specimen for Gram stain and aerobic and anaerobic culture should be obtained from the necrotic center of the lesion to identify the causative organisms.

Predisposing risk factors for necrotizing fasciitis include diabetes mellitus, alcoholism, an immunocompromised state, hypertension, peripheral vascular disease, IV drug abuse, and obesity. Increased age, delay in diagnosis, inadequate debridement during initial surgery, extent of disease on initial presentation, and the presence of diabetes mellitus are all factors that have been associated with an increased likelihood of mortality from necrotizing fasciitis.

Early diagnosis and aggressive management of this lethal disease have led to improved survival. In an earlier series, the mortality rate was consistently higher than 30%, but in more recent series, the mortality rate has decreased to less than 10%.

Successful management of necrotizing fasciitis involves early recognition, immediate initiation of resuscitative measures (including correction of fluid, acid–base, electrolyte, and hematologic abnormalities), aggressive surgical debridement (and redebridement as necessary), and broad-spectrum antibiotic therapy. Many patients benefit from central venous monitoring and high caloric nutritional support.

During surgery, the incision should be made through the infected tissue down to the fascia. An ability to undermine the skin and subcutaneous tissues with digital palpation often confirms the diagnosis. Multiple incisions can be made sequentially toward the periphery of the affected tissue until well-vascularized, healthy, resistant tissue is reached at all margins. The remaining affected tissue must be excised. The wound can then be packed and sequentially debrided on a daily basis as necessary until healthy tissue is displayed at all margins.

Hyperbaric oxygen therapy historically was considered to benefit, particularly in patients for whom culture results are positive for anaerobic organisms. Retrospective studies demonstrated that the addition of hyperbaric oxygen therapy to surgical debridement and antimicrobial therapy appears to significantly decrease both wound morbidity and overall mortality in patients with necrotizing fasciitis. However, more contemporary, large-scale studies have failed to show a benefit of this treatment. Given the technical difficulty with its administration, hyperbaric oxygen treatment should only be considered in hemodynamically stable patients for whom the treatment will not delay surgical management.

After the initial resuscitative efforts and surgical debridement, the primary concern is the management of the open wound. Allograft and xenograft skin can be used to cover open wounds, thus decreasing heat and evaporative water loss. Interestingly, temporary biologic closure of open wounds also seems to decrease bacterial growth. Application of a wound vacuum-assisted closure (VAC) device will also promote wound healing. When spontaneous closure is not likely, the VAC device may allow for the development of a suitable granulation bed and prepare the tissue for graft placement, thereby increasing the probability of graft survival. Finally, skin flaps can be mobilized to help cover open wounds after the wound infections have resolved and granulation has begun.

Obesity

Elderly patients.

The life expectancy of American women continues to increase. In addition, as the baby boomer generation ages, we will see an increasingly larger population of older women who will develop gynecologic cancers. Elderly women are at higher risk of developing gynecologic cancer in that 57% of vulvar cancers, 55% of epithelial ovarian cancers, 41% of endometrial cancers, and 20% of cervical cancers occur in women older than 65 years of age. Although many of these cancers are managed with radical surgery, careful consideration must be given in selection of surgical procedures in women who may be at high risk for surgical complications. In addition to patient’s chronological age, preoperative evaluations that include measurements of frailty, performance status, quality of life, and geriatric assessments can aid greatly in appropriate patient selection for radical surgery. In fact, complications of radiation therapy and chemotherapy are more likely to occur in older patients, so selection of any therapy requires consideration of patient tolerance. In past years, radical surgery was avoided in elderly women. We now know that surgery can be safely and successfully accomplished, despite a patient’s age, if the patient is fully evaluated and determined to be a surgical candidate. There is no doubt that older patients present with more advanced disease and have poorer preoperative performance status and more comorbid conditions than younger patients. Retrospective review of elderly patients with gynecologic cancers demonstrates that 90% of women older than age 65 years can undergo radical surgery as definitive therapy for their gynecologic cancers. Compared with women younger than 65 years, the postoperative mortality rate was 1.5%, and the minor complications and length of stay were similar in the two groups. In women older than 65 years of age who underwent radical hysterectomy for early-stage cervical cancer, there was no perioperative mortality or ureteral fistula. Transfusion requirements and lymphedema were also similar. Febrile morbidity was less common in the older patients, although postoperative small bowel obstruction, bladder dysfunction, and pulmonary emboli were more commonly encountered in the older patients. In a population-based evaluation of 28,651 women undergoing cytoreductive surgery for ovarian cancer across the country, age was significantly associated with increased complication rate (<50 years, 17%; >70 years, ≥30%), including surgical site, medical, and infectious complications. With regard to minimally invasive surgery, in contrast, there is minimal increase in morbidity associated with age. Elderly cohorts of patients undergoing robotic surgery for endometrial cancer have been reported to have equivalent outcomes of blood transfusions, surgical complications, and length of hospital stay while preserving surgical comprehensive staging.

Perioperative management is the key to success when managing elderly women. Cardiac and pulmonary complications are the two most common serious problems encountered postoperatively. Careful preoperative assessment of cardiac status should include assessment for underlying coronary artery disease, valvular heart disease, and chronic congestive heart failure. Several risk-assessment algorithms may be applied to estimate cardiac risk of major noncardiac surgery. Because more than 40% of elderly women have hypertension, optimal blood pressure control should be achieved preoperatively; intraoperative hypotension is one of the most common causes of myocardial ischemia and infarction. Pulmonary complications occur in nearly 40% of elderly women after major abdominal surgery. Because physiologic changes of aging diminish vital capacity, lung compliance, reduced expiratory flow rates, and increased residual volume, elderly patients are more likely to have pulmonary complications after general anesthesia. These women may be at even higher risk if they have chronic obstructive pulmonary disease or asthma. Preoperative assessment may include assessment of pulmonary function by performing spirometry and obtaining an arterial blood gas measurement. Patients with underlying pulmonary disease should have their medical regimen maximized preoperatively, including the use of bronchodilators and corticosteroids. Conduction anesthesia should be considered in consultation with an anesthesiologist to avoid the pulmonary complications more often encountered with general anesthesia.

Avoiding perioperative hypothermia and hypoxemia are extremely important to avoid additional cardiac oxygen consumption. Invasive monitoring and planned ICU admission should be considered in any circumstance when there is an increased risk of cardiac or pulmonary complications. Care must also be taken when ordering pharmacologic agents because elderly patients may have altered GI absorption and decreased renal or hepatic clearance of specific drugs. Consultation with a clinical pharmacist is advised to establish the correct dose of drug for patients with altered renal or hepatic function.

Radiation complications in elderly patients are also increased. Thin, hypertensive patients appear to be at greater risk for radiation therapy complications to both the GI and genitourinary tracts. It appears that elderly women tolerate initial therapy poorly and often require delays in treatment or discontinuation of treatment because of acute toxicity such as diarrhea, dehydration, or neutropenia. This observation, then, requires carefully planned treatment decisions as to whether the patient would be best treated with surgery or radiation therapy. Neither is without risk, and it cannot be assumed that radiation therapy is necessarily less toxic.

Acute complications.

Nearly all patients receiving external radiation to the pelvis will develop radiation proctitis or enteritis with associated diarrhea. This problem commonly begins after 2 weeks of radiation therapy and is usually easily managed by dietary modification and antidiarrheal medications (diphenoxylate; Lomotil). As a rule, the diarrhea resolves within 7 to 10 days of completing radiation. Some of the transitory symptoms are tenesmus and the passage of mucus and even blood per the rectum. Diarrhea and abdominal cramping characterize small intestinal irritation (radiation enteritis). This problem is more common and more severe when a portion of the small intestine is fixed in the pelvis as a result of adhesions or other pathologic conditions. Anorexia may also occur during radiation therapy. If nausea and vomiting occur, the patient should be evaluated for dehydration. This is more common when concurrent chemotherapy is being given along with the radiation. IV hydration and correction of electrolytes is occasionally required. If dehydration is severe, radiation should be interrupted until these acute side effects are corrected.

The patient should have a complete blood count weekly during radiation therapy. If the hemoglobin decreases below 10 g/dL, PRBC transfusion is advised to achieve improved tumor kill. Occasionally, radiation of the pelvic bone marrow will result in neutropenia or thrombocytopenia. In severe cases, radiation will need to be temporarily interrupted. In nearly all cases, the acute side effects of radiation therapy will resolve after the radiation course is completed.

Chronic conditions.

Radiation injury to the small intestine may manifest itself at any time after therapy and may vary from chronic diarrhea to small bowel obstruction or fistula. A typical patient with small bowel injury will initially present with postprandial abdominal cramps and pain, anorexia, and diarrhea. About half of small bowel injuries occur within 1 year after radiation, and three-fourths occur within 2 years. These symptoms are more common in patients who have had a prior laparotomy. Initial conservative management focuses on dietary modification (avoiding green leafy vegetables, milk products, and fried foods). Antidiarrheal drugs and oral cholestyramine (which binds bile salts) are often useful in managing symptoms.

As small bowel injury progresses, fibrosis of the injured bowel wall develops, leading to stricture and partial or complete obstruction. Patients usually present with worsening abdominal pain, cramps, diarrhea, and vomiting. Sometimes the intermittent obstruction goes unrecognized until a significant weight loss is recorded. If medical management of a partial small bowel obstruction fails, surgical intervention is the course of last resort. The decision to proceed with surgical intervention in cases of intermittent obstruction is a difficult one and should be undertaken with proper preoperative preparation. Often, patients have developed a significant degree of malnutrition and should have their nutritional status corrected with preoperative TPN. Mechanical bowel preparation is mandatory, although sometimes it must be limited to enemas because the patient’s small bowel obstruction will not allow the ingestion of oral cathartics. Dilated loops of bowel should be decompressed preoperatively with NG suction. Surgical correction depends on the situation encountered at the time of surgical exploration. The obstruction is usually found to be bowel adherent in the pelvis that has been radiated. The bowel usually is thickened, edematous, and fibrotic. The two primary surgical options are resection of the obstructed loops with either reanastomosis or small bowel bypass. In either event, it is preferable to make anastomoses to intestinal segments that have not been radiated in order to have maximum opportunity for healing. Care should be taken to have adequate perfusion and no tension on the anastomosis. Perforation or fistula, if present, must be isolated and diverted; more extensive surgery (resection and anastomosis) must be done only if it is technically feasible ( Fig. 16.10 ).

Only gold members can continue reading. Log In or Register to continue

Share this:

• Click to share on Twitter (Opens in new window)
• Click to share on Facebook (Opens in new window)

Related

Related posts:

Preinvasive Disease of the Vagina and Vulva and Related Disorders Adenocarcinoma of the Uterine Corpus Epithelial Ovarian Cancer Nutritional Therapy Blood Component Therapy Role of Minimally Invasive Surgery in Gynecologic Malignancies

Stay updated, free articles. Join our Telegram channel

Join