Publications Update # 65

Non-Medical Article of the Week

Repost from the past but relevant given the start of the new academic year

Link to the video: How to succeed as a gynecologic oncology fellow and prepare to be a successful attending

Palliative Care and Symptom Management

A colostomy for large bowel obstruction at the end of life: What do patients gain from palliative surgery? - PubMed

A significant proportion of patients died within 60 days of surgery, and many had high healthcare utilization at the end of life.

PubMedRoni Nitecki Wilke

This is an excellent paper from MDACC evaluating the outcomes of patients undergoing colostomy for significant bowel obstruction. I think the data presented in this paper are beneficial during the goals of care conversations. I highly recommend that you read the paper. Here are some of the highlights:

• Limited Survival Benefit: The median overall survival (OS) for patients undergoing palliative colostomy was only 4.5 months, with a significant proportion (15%) not surviving beyond 30 days postoperatively.
• High Morbidity and Mortality: A substantial number of patients experienced poor outcomes, with 63% being re-admitted to the hospital, 53% visiting the emergency department, and 18% admitted to the ICU within the last 30 days of life, indicating high healthcare utilization and significant morbidity.
• Poor Performance and Prognosis Indicators: Poor performance status and platinum resistance were associated with worse overall survival, suggesting weakened patients are less likely to benefit from the procedure.
• Lack of Further Treatment: Approximately half of the patients did not receive any systemic treatment following the colostomy, implying that the surgery did not significantly extend life or improve the quality of life to the extent that further treatment was deemed worthwhile.
• End-of-Life Events: The study indicates that large bowel obstructions are often end-of-life events for patients with advanced gynecologic malignancies, and the high rate of hospitalizations and emergency interventions post-surgery further underscores the limited palliative benefit of the procedure.

Focused Topic: Stoma

(Repost from Publications Update # 23)

Patient Perspective

Before you go any further, please read this fascinating perspective from a patient who has had a stoma for over 40 years. Here is a link you can share with patients about to embark on a journey with an ostomy: https://www.ostomy.org/

Intestinal Stoma: An Open Letter to Surgeons from an Ostomate

PubMed Central (PMC)Kenneth W. Aukett

Guidelines

These guidelines from the American Society of Colorectal Surgeons will answer most of your questions. If you read carefully, these guidelines might question most of your practices.

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for Ostomy Surgery - PubMed

The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for Ostomy Surgery

PubMedBradley R Davis

Preoperative Marking

Key Points:

• Preoperative stoma site marking is recommended for all patients undergoing planned ostomy surgery.
• When selecting a location for the ostomy barrier, choosing a spot at least two inches away from bony areas, the midline, creases, scars, and folds is essential. This will provide enough space for the barrier to stick correctly. Let the ostomy barrier serve as a guide when choosing the right spot.

High Output Ileostomy

Key Points:

1. Ensure good skin protection/bag fitting.
2. Exclude causes other than a short bowel (e.g., obstruction).
3. Rehydrate and stop thirst.
4. Restrict oral hypotonic fluid.
5. Sip a glucose/salt solution +/- magnesium supplements.
6. Start loperamide (high dose) before food.
7. Start a proton pump inhibitor (especially if a net ‘secretory output’).
8. Consider reducing oral insoluble fiber intake.
9. Monitor random urinary sodium concentration and serum magnesium.
10. Patients with a short bowel (less than 2 m remaining) needing parenteral support may be considered for a glucagon-like peptide-2 analog.

How to manage a high-output stoma - PubMed

A high-output stoma (HOS) or fistula is when small bowel output causes water, sodium and often magnesium depletion. This tends to occur when the output is >1.5 -2.0 L/24 hours though varies according to the amount of food/drink taken orally. An HOS occurs in up to 31% of small bowel stomas. A hig …

PubMedJeremy M D Nightingale

Preventing Readmissions

Patients with a diverting loop ileostomy may face difficulties in the initial few months due to high output. This often results in readmissions within the first few days after discharge. To ensure patients have a clear understanding of ileostomy management essentials, our ostomy nurses use a straightforward checklist at the University of Michigan:

Patient Discharge Checklist

Patient autonomy-centered self-care checklist reduces hospital readmissions after ileostomy creation - PubMed

Implementation of a patient-centered, self-care-oriented postoperative education checklist was associated with significantly reduced odds of readmission after ileostomy creation.

PubMedKarin M Hardiman

That is it for this week.

Sentinel Lymph Nodes in Cervical Cancer

Most of you are familiar with the sentinel lymph node dissection data in endometrial cancer. The FIRES Trial was pivotal in changing the practice. Furthermore, the ongoing use and safety of minimally invasive hysterectomy in endometrial cancer have facilitated the widespread adoption of sentinel lymph node dissection.

In contrast, the LACC trial and several retrospective reviews have significantly influenced the shift from minimally invasive to open surgery in radical hysterectomy for cervical cancer. Sentinel lymph node dissection during open radical hysterectomy is feasible using the hand-held Firefly camera (more manageable) and the laparoscopic camera (more challenging). However, most practices in the US utilize robotic surgery for hysterectomy, and the robotic camera cannot be used for sentinel lymph node dissection during open radical hysterectomy. Consequently, the adoption of this procedure in cervical cancer has been lower.

It is also important to note that while the SHAPE trial now eliminates the need for radical hysterectomy in low-risk cervical cancer, patients still require lymph node assessment. Here is a summary of all the critical studies in cervical cancer and sentinel lymph node dissection:

Sentinel lymph node pathological ultrastaging: Final outcome of the Sentix prospective international study in patients with early-stage cervical cancer - PubMed

NCT02494063 (ClinicalTrials.gov).

PubMedRoman Kocian

This most recent publication of the SENTIX trial emphasises the importance of ultra-staging in cervical cancer sentinel lymph nodes. Here is the summary findings

Bottom line: 4 section per node !!

Hypothesis:
Intensive ultrastaging of sentinel lymph nodes (SLNs) in early-stage cervical cancer increases the detection rate of metastatic involvement compared to standard pathological assessment.

Inclusion Criteria:

• Patients with early-stage cervical cancer (T1a1/LVSI+ to T1b2, <4 cm, ≤2 cm for fertility-sparing)
• No suspicious lymph nodes on imaging
• Bilateral SLN detection

Exclusion Criteria:

• Intraoperatively detected parametrial invasion
• Bulky lymphadenopathy
• Distant cancer spread
• Neoadjuvant chemotherapy
• History of pelvic or abdominal radiotherapy
• HIV infection or AIDS

Primary Endpoint:
Recurrence rate at 24 months after primary surgery

Experimental Arm(s):

• Patients underwent SLN biopsy followed by intensive pathological ultrastaging (paraffin blocks sectioned at 150-μm intervals/levels)
• Intraoperative frozen section examination was performed

Control Arm (or standard therapy):

• Patients with failed SLN detection or unilateral detection underwent systematic pelvic lymphadenectomy

Results:

Conclusions:

• Intensive SLN ultrastaging significantly improves the detection of metastatic involvement in early-stage cervical cancer.
  Examining four levels from paraffin blocks detects over 90% of node-positive cases, suggesting this should be a standard practice

Limitations:

• Results might not be generalizable to less experienced centers.

That's it for today!