24 Gynecologic Surgery OB.GYN.

NEWS • April 1, 2007

Sentinel-Node Biopsy Defines Risk in Vulvar Ca

BY ROBERT FINN
San Francisco Bureau
S A N T A M O N I C A , C A L I F. —
It’s safe to rely on sentinel-node
biopsy for assessing the risk of
metastasis in women with early-
stage vulvar cancer, Dr. Ate van
der Zee said at the biennial meet-
ing of the International Gyneco-
logic Cancer Society.
The results of a large, multi-
center, observational study indi-
cate that sentinel-node biopsy
has a sensitivity of 95.4% in pre-
dicting whether unifocal vulvar
cancer has metastasized, with a
negative predictive value of
98.3%.
These data come from a total
of 367 women, median age 66
years, with stage T1 or T2 squa-
mous cell cancer of the vulva,
said Dr. van der Zee of the Uni- lymphadenectomy. The remain- Another two of the false neg- The women who underwent
versity Medical Center Gronin- ing sentinel node–negative pa- atives were attributed to techni- only sentinel-node biopsy had
gen (the Netherlands). tients were followed for a medi- cal error, and no explanation one-third the rate of wound
None of the patients had clin- an of 35 months. could be found for the remaining breakdown and one-quarter the
ically suspicious groin nodes, and During that time, 8% of the three. rate of cellulitis as did those
their sentinel nodes were detect- patients had a local recurrence of Among the 21 sentinel who underwent lymphadenec-
ed with radioactive tracer. their cancer, and 2.9% had a node–negative patients with re- tomy.
Patients whose sentinel- current local disease, the Moreover, the median length
node biopsies were nega- The 3-year survival rate was median time to recurrence of stay in the hospital was sig-
tive did not have full lym- 96.5% among women who were was 21 months, and 4 of nificantly shorter for sentinel
phadenectomies, but the patients died. node–negative women. They
rather were followed up sentinel-node negative, and The 3-year survival rate also had much lower rates of re-
closely by an experienced 80.5% among women who were was 96.5% among women current erysipelas and lym-
physician. who were sentinel-node phedema.
Physicians treated the sentinel-node positive. negative, and 80.5% Although he is enthusiastic
primary tumor with a among women who were about the potential for sentinel-
wide local excision in 91% of the groin recurrence. sentinel-node positive. node biopsy in women with vul-
women, with the remainder re- Of the seven patients who had There was significantly less var cancer, Dr. van der Zee cau-
ceiving either radiotherapy or a groin recurrence, two had mul- short-term and long-term mor- tioned that this should be
radical vulvectomy. tifocal disease, and the study pro- bidity among the sentinel performed only by an experi-
Overall, 32% of the patients tocol was subsequently amended node–negative women, com- enced team, and preferably
had positive biopsies of sentinel to exclude women with multifo- pared with those who underwent within the context of a clinical
lymph nodes and went on to cal disease. lymphadenectomy. trial. ■

Preserve Ovarian Function ‘Muscle Welding’ Is Last, Best

With Laparoscopic Detorsion Way to Stem Presacral Bleeding
B Y M I C H E L E G. S U L L I VA N
Mid-Atlantic Bureau
O R L A N D O — Laparoscopic untwisting
of an adnexal torsion can almost always
preserve ovarian function and avoid the
need for an adnexectomy, Dr. Kazem
Nouri said at a meeting on laparoscopy
and minimally invasive surgery.
“These days, there is no longer any
question about whether laparoscopy or la-
parotomy is the best way to deal with ad-
nexal torsion. The answer is laparoscopy,”
said Dr. Nouri of the General Hospital of
Vienna.
“The question is whether to go with
detorsion or removal of the adnexa,” he
said. “In my opinion, detorsion is justified
because even if the ovary appears devas-
cularized, function can be preserved in al-
most all cases.”
Ovarian torsion most often occurs in
conjunction with a cyst and is seen more
frequently in the right ovary than in the
left.
The symptoms include nonspecific ab-
dominal pain, which can have either grad-
ual or sudden onset and may radiate to the
front, back, or groin. Nausea and vomit-
ing are present in up to 70% of cases.
The differential diagnosis includes ap-
pendicitis, ectopic pregnancy, pelvic in-
flammatory disease, diverticulitis, and re-
nal colic.
Torsion is usually diagnosed by ab-
dominal or transvaginal ultrasound. The
classic finding is the “whirlpool sign”—a
spiraling line that shows the twisted pedi-
cle. Ultrasound may also show an en-
largement of the affected ovary and devi-
ation of the uterus toward the affected
side.
“None of these findings has 100% speci-
ficity and sensitivity, however,” said Dr.
Nouri. “The only way to be 100% sure is
to do a diagnostic laparoscopy.”
Adnexal torsions have historically been
treated by laparotomy with adnexecto-
my, he said. “Gynecologists were afraid of
sepsis and pulmonary embolism associat-
ed with the torsion. And they were not
that concerned about preserving the ovary
because they held the opinion that after
torsion, the ovary was nonfunctional.”
The introduction of laparoscopic detor-
sion proved that ovarian function can be
preserved in almost 90% of cases, Dr.
Nouri said at the meeting sponsored by
the Society of Laparoendoscopic Sur-
geons.
In addition, the fear of pulmonary em-
bolism associated with the condition ap-
pears unfounded. A 1999 review of about
600 patients treated with either laparo-
scopic detorsion or laparotomy with re-
section found only two cases of pul-
monary embolism, both in women who
underwent laparotomy.
Embolism appeared to be associated
with length of hospital stay: One woman
was hospitalized 3 days before the surgery,
and the other, 4 days.
Laparoscopic detorsion involves careful
manipulation of the adnexa, making sure
to untwist the tissue in the correct direc-
tion. If there is a cyst, opinions are divid-
ed on whether to remove it at the time of
the detorsion.
“Reports in the literature mention that
the cystectomy can be complicated by
edematous tissue, and some advise wait-
ing for 3 or 4 weeks before removing the
cyst,” Dr. Nouri said.
Other surgeons prefer to remove the
cyst for immediate biopsy.
“I have treated eight torsions, and in
some cases I did the cystectomy later. In
others I thought the ovary looked suspi-
cious, so I performed it right away.”
An oophorectomy is usually performed
only in the case of recurrent torsion, he
said. ■ own, so that the clamp does not stick to
BY MITCHEL L. ZOLER
Philadelphia Bureau
F O R T L A U D E R D A L E , F L A . — Any-
one who operates in the pelvis should
know how to manage presacral bleeding
because it occasionally happens to most
surgeons, Dr. Herand Abcarian said at an
international colorectal disease sympo-
sium sponsored by the Cleveland Clinic
Florida. “Muscle welding” is an effective
way to stop presacral venous bleeding
when other steps fail.
In a series of 426 patients at the Mayo
Clinic, Rochester, Minn., who had surgery
for rectal cancer during the early 1990s,
3% had presacral bleeding. Dr. Abcarian’s
suggested management sequence is initial
tamponade with packing. The patient
should be put in the reverse Trendelen-
burg’s position while exposure of the
bleed is set up, followed by digital pressure
and then attempted repair with suture,
clips, cautery, or argon beam. If none of
these work, a properly placed thumbtack
can sometimes staunch the flow.
But muscle welding is almost always ef-
fective as a last-ditch attempt to stop the
bleeding before temporarily packing the
patient and waiting a few days for the pa-
tient to stabilize. “By far it’s the most suc-
cessful method for controlling presacral
bleeding,” said Dr Abcarian, chairman
and professor, department of surgery,
the University of Illinois at Chicago.
Welding is done by harvesting a 3- to
4-cm by 1- to 2-cm strip of rectus mus-
cle from the lower abdominal incision,
below the midline. The muscle is placed
directly over the bleeding point, held
there with the tip of a clamp, and treat-
ed with a cautery probe turned up to
maximum coagulating power. The
clamp should be withdrawn after a few
seconds, once the patch sits firmly on its
the burned muscle fragment. Contin-
ued cautery power is applied until the
muscle takes on the appearance of shoe
leather and becomes a coagulum that
seals the bleeding point.
A thumbtack may work, but only
when it’s correctly applied. The tack
must be placed over the bleeding point
and forcefully driven into the anterior
sacral table, causing a crunching of the
bone. Collapsing the bone is vital for
stopping flow because it’s the bone drop-
ping into the sacral plexus that helps
block further bleeding. Although place-
ment of a second tack might occasionally
be called for, placing multiple tacks
should be avoided, Dr. Abcarian advised.
When tacks and muscle welding fail to
staunch the flow, packing for several
days is the last resort. A layer of Silastic
or a piece from a rubber glove is placed
over the bleeding, and then the pelvis is
packed tightly to produce tamponade.
The patient should be stabilized and nor-
malized for coagulation factors, hemo-
globin, and vital functions, and returned
to the operating room 3 days later to
have the pack removed and the bleeding
assessed. In rare cases when bleeding
continues, the packing should be redone
and the bleeding reassessed as needed
until it stops.
The most common cause of presacral
bleeding is a forceful lifting of the rectum
from the sacral surface and blunt dissec-
tion of the rectum in a narrow male
pelvis. The best way to prevent a pre-
sacral bleed is by appropriately position-
ing the patient, using excellent exposure
and lighted retractors, and by using
sharp—not blunt—dissection.
Sometimes it is tempting to simply
pull the rectum straight up and out of
the way, but this can cause a tear. “The
less blunt dissection, the better,” Dr. Ab-
carian said. ■