Publications Update # 45

Last updated on Mar 4, 2024

Photo by Seyedeh Hamideh Kazemi / Unsplash

Happy Birthday, GYOEDU Plus

Publications Update # 1

Date: 01-25-23

GYOEDU PlusShitanshu Uppal

A year ago, I started the process of transforming GYOEDU from a video website into a newsletter, and today marks its first anniversary. My heartfelt thanks go out to everyone who contributed to making this a successful endeavor. Reflecting on what to share on GYOEDU's birthday, a recent personal experience led me to choose the topic of death.

I've just lost a patient I've been caring for since I started as an attending ten years ago. To those starting or considering a career in oncology, I want to share an honest insight: dealing with the loss of patients never gets easier. It's a challenging aspect of our job, but it's also what makes it deeply meaningful. I wouldn't choose any other profession, as being part of someone's life in such a significant way is an immense privilege.

Take some time today to listen to this talk by Alua Arthur, where she urges us to view our lives through the lens of death. She encourages us to think about what we need to do to be at peace with ourselves, to live fully in the present, and to approach death gracefully. While centered on our death, this perspective can profoundly shape how we live our lives.

May you be forever in peace, MGB.

Question of the Week

A 65-year-old patient calls you on Sunday morning, a day before her scheduled interval debulking procedure. She misplaced the list your nurse gave her detailing which medications she should hold preoperatively. Which one of these medications should she not take on Sunday evening?

A) Simvastatin

B) Levothyroxine

C) Pantoprazole

D) Lisinopril

E) She does not need to withhold any of the above medications

Answer at the end of the newsletter

Surgical Techniques

Finding ureters in a Tough Pelvis

There are several ways to identify ureters. Stents are the most widely used in open surgery and allow the surgeon to identify the ureter by feel. However, in laparoscopy, there are two ways:

Lighted ureteral stents are great for visualizing the ureter during a complex case - endometriosis or obliterated pelvis. However, they add significant costs and equipment to the case.

ICG injected in the ureter

I tried this approach in one of my cases, where we injected the ureter with a 5F stent inserted in the lumen for approximately 3-4 cm. We used 3 cc in each lumen and used the remaining on the cervix for endometrial sentinel lymph node dissection. One team member performed the cystoscopy and ureteral injection while the fellow and resident secured the ports, so no additional time was needed (in our institution, we have privileges to do cysto with stents, and urology is not routinely consulted for stents). Identification of the ureter was a breeze

If you cannot see the video in this email - click this link to watch it: https://vimeo.com/user114850089/uretericg?share=copy

Mini Tutorial - Adenoma Malignum

What is Adenoma Malignum?

Adenoma malignum, also known as minimum deviation adenocarcinoma, refers to a highly differentiated form of adenocarcinoma of the cervix. First described in 1870 by Gusserow, it is characterized by its deceptively benign histological appearance, making it difficult to recognize as malignant using the usual criteria for adenocarcinoma of the cervix. A notable characteristic of adenoma malignum is its resistance to radiotherapy.

How is the diagnosis made?

Diagnosing adenoma malignum (minimum deviation adenocarcinoma) involves several steps due to its challenging nature. Clinically, patients often present with symptoms like watery or mucous discharge or abnormal uterine bleeding. Upon physical examination, the cervix is typically firm and indurated. Ultrasonic examination can reveal a multiloculated tumor in about two-thirds of cases.

However, standard diagnostic methods like Pap smears are often inadequate, as they show precancerous or malignant cells in only one-third of patients. Punch biopsies are also not helpful in diagnosing adenoma malignum. Instead, a deep wedge or cone biopsy is necessary to demonstrate the depth of glandular penetration. Frequently, adenoma malignum is misdiagnosed as a benign condition, and the accurate diagnosis only becomes apparent after the patient has undergone an extra fascial hysterectomy.

Treatment

The recommended treatment for local adenoma malignum (minimum deviation adenocarcinoma) in operable cases includes surgical intervention. The prognosis for such cases appears very good when the disease is operable. Additionally, adjuvant (chemo)radiation may be administered postoperatively for cases with high-risk features. Although several of these tumors are radioresistant, I typically avoid radiating these tumors. It's important to note that for more advanced cases of adenoma malignum, lymph node metastases are common, and the overall prognosis is poorer.

Based on the Korean paper (see below), risk factors include

Risk Factor
Vaginal Invasion (VI)
Parametrial Invasion (PMI)
Resection Margin (RM)
Nodal Status
Lymphovascular Invasion (LVI)

Patients without identified risk factors exhibited a recurrence-free survival (RFS) of 97.0% at three years. In contrast, those with more than one of the risk factors had a 3-year RFS of 65.4%

Two recent papers to read:

In my personal experience, Bevacizumab works in stabilizing the growth of these tumors. The MSKCC paper seems to suggest that ERBB2 mutations in these tumors might make them suseptible to trastuzumab.

Correct Answer: E or D

E) Based on this trial, whether you hold or give ACE inhibitors does not matter. However, many anesthesiologists will still prefer to hold ACE/ARB if the expected blood loss is high. On the other hand, if the patient has brittle HTN, giving ACE/ARB is acceptable.

D) is also an acceptable answer since the outcome is similar.

Hypothesis

Comparison of hypotension-avoidance and hypertension-avoidance strategies on major vascular complications after noncardiac surgery.

Inclusion Criteria

Patients aged ≥45 years, undergoing inpatient noncardiac surgery, with a history of vascular disease or risk factors, and receiving long-term antihypertensive medications.

Primary Endpoint

A composite of vascular death, nonfatal myocardial injury, stroke, and cardiac arrest at 30 days.

Experimental Arm

Hypotension-avoidance strategy: Intraoperative mean arterial pressure target ≥80 mm Hg; withholding renin–angiotensin–aldosterone system inhibitors before and for 2 days after surgery; other long-term antihypertensive medications administered only if systolic blood pressure ≥130 mm Hg.

Control Arm

Hypertension-avoidance strategy: Intraoperative mean arterial pressure target ≥60 mm Hg; all antihypertensive medications continued before and after surgery.

Results

Outcome	Hypotension-Avoidance Group	Hypertension-Avoidance Group	P-value	Hazard Ratio
Primary composite outcome	520/3742 (13.9%)	524/3748 (14.0%)	0.92	0.99 (0.88 to 1.12)

Conclusions

The hypotension-avoidance and hypertension-avoidance strategies resulted in similar incidences of major vascular complications in patients undergoing noncardiac surgery.

That's it for this week.

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