Unnecessary Laparotomy Avoidance - - Outcome of 257 Consecutive Adnexal
نویسندگان
چکیده
--Study Objective: To demonstrate the safety of minimally invasive surgical treatment of 8 – 13 cm adnexal masses felt to be benign, to confirm the negative predictive value of ACOG Committee Opinion 280 for selecting women whose adnexal masses are unlikely to be malignant and, based on these data, to advocate for acceptance of a new treatment algorithm featuring Minimally Invasive Surgery in the treatment of both benign and malignant ovarian lesions. Design: Retrospective Chart Review (Canadian Task Force Classification III). Setting: Community hospitals and private Gynecologic Surgery practice. Patients: 257 consecutive patients with adnexal masses of 8 – 13 cm on Pre-Operative ultrasound examination meeting criteria set forth in ACOG Committee Opinion 280, “Role of the Generalist Obstetrician-Gynecologist in the Early Detection of Ovarian Cancer.” Intervention: Patients meeting the selection criteria were scheduled for Operative Laparoscopy, Washings, Adnexectomy, Bagging and Colpotomy. Procedures were aborted if frank malignancy was encountered and excluded if the lesion was judged not to be a primary ovarian process. Patients were assessed post-procedure and outcomes monitored. Measurements and Main Results: Of 257 consecutive cases with stated inclusion criteria, six were found to have disseminated ovarian malignancy at the time of laparoscopy and eleven were judged not to be candidates for inclusion in this study at the time of laparoscopy. A total of 240 patients successfully completed intended treatment (93.38%) and 234 of these did not require admission (97.5%). The procedure is well tolerated with relatively few complications. Intra-operative rupture of the ovarian capsule was extremely rare in our series. Capsular rupture was noted in just 1.25% of cases. The most common lesions were cystadenomas, endometriomas, cysts and mature teratomas accounting for 85% of all cases. Borderline tumors accounted for 5% while invasive ovarian malignancy represented 3.75% of the specimens. Laparoscopies abandoned based on presumption of disseminated disease had significant findings at the time of definitive staging by Gynecologic Oncologists: Stage I0%, Stage II – 16.67%, Stage III – 50% and Stage IV – 33.33% In the nine cases we treated that later returned invasive carcinoma on final pathology, all were believed to be Stage I disease at the time of referral to Gynecologic Oncologists. No capsules had excresences, there was no disease noted elsewhere in the abdomen and pelvis, but six had positive washings. Definitive staging upstaged four of the nine lesions or 44.44% Finally, we examined the relationship of menopausal status and cancer Stage of all fifteen patients found to have invasive ovarian malignancy. Being postmenopausal conferred a greater likelihood of having any ovarian malignancy (8 / 88 or 9.09%) compared with pre-menopausal women (7 / 158 or 4.43%). The Negative Predictive Value of ACOG Committee Opinion 280 as a de-selector for having invasive ovarian malignancy in our population was 95.57% for premenopausal and 90.91% for postmenopausal women. Conclusions: Laparoscopic adnexectomy, bagging and colpotomy is a desirable goal for patients meeting selection criteria affording a minimally invasive approach with attendant benefits including outpatient treatment, few complications, low likelihood of iatrogenic rupture of the ovarian capsule and low necessity for re-operation after final pathology is evaluated. Negative predictive value of ACOG Committee Opinion 280 is confirmed in a community GYN practice and is recommended to form basis of new treatment algorithm for women with adnexal masses.
منابع مشابه
Laparoscopic Management of Adnexal Masses
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