Better outcomes when gyn oncs are trained to perform upper abdominal surgeries

It also may enable more patients to have primary surgery, reduce the burden on the surgical team to schedule more complex procedures, and help eliminate the need to involve other specialties in the procedures.

The findings are from a prospective United Kingdom study in the journal Minerva Ginecologica.1

“The aim of surgery for patients with advanced ovarian cancer is to remove all visible disease in the pelvis and abdomen,” said co-author Nikos Akrivos, MD, PhD, a consultant gynecological oncologist and head of the 3rd Department of Gynecologic Oncology at Hygeia Hospital in Athens, Greece.

“However, there is significant variation in surgical technique among gynecological oncologists. Also, marked differences in the presence of disease in the upper abdomen remain one of the main reasons for not achieving the desired surgical outcome.”

The aim of the study was to present the experience of Dr. Akrivos and his surgical colleagues in developing surgical skills required to resect metastatic ovarian cancer in the upper abdomen.

The study comprised 126 patients undergoing cytoreductive surgery at Norfolk and Norwich University Hospital, United Kingdom, for stage IIIC and IV epithelial ovarian cancer that required at least one surgical procedure in the upper abdomen. At the time the research was done, Dr. Akrivos was a subspecialty fellow in gynecologic oncology at that hospital.

Patients were divided into three equal groups: Group 1, which underwent surgery between December 2012 and July 2014; Group 2, which had scheduled surgery between August 2014 and March 2016; and Group 3, which underwent surgery between April 2016 and March 2018.

The percentage of patients undergoing primary surgery in groups 1, 2 and 3 was 47.6%, 50.0% and 73.8%, respectively (P =0.02).

In comparison to groups 1 and 2, Group 3 had a significant increase in the percentage of patients undergoing cholecystectomy (P = 0.02); resection of disease from porta hepatis (P = 0. 008); liver capsulectomy (P < 0.001); lesser omentectomy (P < 0.001); and celiac trunk lymphadenectomy (P < 0.001).

But among the three groups, there was no difference in the percentage of patients undergoing splenectomy, diaphragmatic peritonectomy/resection and gastrectomy.

Complete cytoreduction was achieved in 54.8%, 35.7%, and 64.3% of patients in groups 1, 2 and 3, respectively (P = 0.028).

There was also no significant difference in the occurrence of grades 3 to 5 complications among the three groups.

However, a liver surgeon was required in 9.1%, 5.6%, and 0% of cases in groups 1, 2 and 3, respectively.

“We found that aggressiveness of cytoreductive surgery increased with time, as reflected in the percentage of patients that had optimal surgical outcome,” Dr. Akrivos told Contemporary OB/GYN.

“This is to be expected, as our knowledge and surgical skills improved during the study period. Interestingly, we observed no increase in the rate of complications, despite an increase in surgically complex cases. This likely is due to our multidisciplinary approach to perioperative care management,” Dr. Akrivos said.

The study underscores the need to train and educate gynecological oncologists in acquiring skills for performing surgery on the upper abdomen.

“Collaboration with colleagues from other disciplines such as hepatobiliary or upper gastrointestinal tract surgeons is required to develop or improve surgical skills,” Dr. Akrivos said. “Cadaveric training is also necessary to improve understanding of the relevant surgical anatomy.”

Furthermore, collaborating with multiple gynecological oncology surgeons in complex upper abdominal procedures can facilitate learning, according to Dr. Akrivos, whereas monitoring of surgical morbidity is of greatest importance.

“In short, surgical management of metastatic ovarian cancer can be safely assigned to gynecological oncologist surgeons,” Dr. Akrivos said.

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Dr. Akrivos reports no relevant financial disclosures.

Reference

1. La Russa M, Liakou CG, Akrivos N, et al. Minerva Ginecol. Learning curve for gynecological oncologists in performing upper abdominal surgery. Published on July 17, 2020. doi:10.23736/S0026-4784.20.04605-5