Emily M. Hinchcliff1, 2
(1)
Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women’s Hospital, Boston, MA, USA
(2)
Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, USA
Emily M. Hinchcliff
Email: ehinchcliff@partners.org
Keywords
Gynecologic oncologyPostoperative complicationLarge bowel obstructionAnastomotic leakFascial dehiscenceNeutropenic fever
Background
Ovarian Cancer
Primary ovarian malignancies occur in 1.3 % of women in their lifetimes [1]. Risk factors for epithelial ovarian cancer (the most common type) include advancing age, a family history of ovarian cancer, and genetic mutations conferring increased risk, including BRCA1 and BRCA2 [2]. Non-epithelial ovarian cancers include germ cell tumors, which often occur in young patients, and sex cord stromal tumors, which can present in any age group. Non-epithelial tumors are generally associated with a very favorable prognosis.
Cervical Cancer
Cervical cancer is diagnosed in 0.6% of women in their lifetimes and is the most common gynecologic cancer worldwide [1]. The majority are squamous cell carcinomas; risk factors are smoking, low socioeconomic status, immunosuppressive therapy, and infection with human papillomavirus (HPV), particularly strains 16 and 18 [3]. Cervical adenocarcinomas are less common but account for an increasing percentage of cervical cancers because they are less effectively diagnosed by Pap smears [4].
Uterine Cancer
By far the most common cancer of the uterus is endometrial cancer; in their lifetimes, 2.8 % of women will be diagnosed with endometrial cancer, the majority of which are adenocarcinomas [1, 5]. Risk factors for endometrial cancer include obesity, unopposed estrogen exposure—either through medications or anovulation—advanced age, and family history, particularly Lynch syndrome, an autosomal dominant syndrome that increases the risk of endometrial and colorectal cancers [5].
Vulvar Cancer
In their lifetimes, 0.3 % of women will be diagnosed with vulvar cancer [1]. In younger women, vulvar cancers are associated with HPV infection, vulvar intraepithelial neoplasia, and smoking, while these associations are not observed as frequently in postmenopausal women, in whom vulvar cancer is associated with vulvar inflammation and lichen sclerosis [6].
Vaginal Cancer
Vaginal cancer is an uncommon gynecologic cancer; approximately 4,000 cases are diagnosed per year [7]. The majority are squamous cell carcinomas, which are associated with the same risk factors as squamous cell carcinoma of the cervix [8].
Gestational Trophoblastic Disease
Gestational trophoblastic disease (GTD) is the abnormal proliferation of trophoblastic tissue, occurring in approximately 0.1 % of pregnancies (including live births, miscarriages, and ectopic pregnancies), most of which are hydatidiform moles [9]. Malignant forms of GTD include invasive mole, choriocarcinoma, placental site trophoblastic tumor, and epithelioid trophoblastic tumor. Risk factors include advanced maternal age and a history of gestational trophoblastic disease [10]. Please see Chap. 8, Spontaneous Abortions, for more information on molar pregnancy.
Radical Hysterectomy
Radical hysterectomy refers to the removal of the uterus, parametrium, and upper vagina en bloc, with or without salpingo-oophorectomy. The extent of dissection is determined by the indication for the more radical surgery, and similarly, complications and postoperative considerations depend on the extent of the initial surgery. Indications for radical hysterectomy include but are not limited to cervical cancer up to stage IIA, stage II endometrial cancer if feasible, upper vaginal carcinoma, and non-oncologic indications such as extensive pelvic adhesions.
Urinary retention is particularly common following radical hysterectomy; long-term postoperative urinary tract dysfunction is observed in 30–85 % of women following radical hysterectomy, likely due to disruption of sensory or motor pathways to the detrusor muscle or due to direct bladder injury [11]. Therefore, it is common (though debated) to leave a Foley catheter in place for bladder decompression for 2 weeks postoperatively. Please refer to Chap. 16, Complications of Minimally Invasive Gynecologic Surgery for more information on the diagnosis and management of postoperative urinary retention.
Trachelectomy
A trachelectomy entails the surgical removal of the cervix with preservation of the uterine body, generally performed for fertility preservation. Candidates for trachelectomy are usually less than 40 years of age, desiring future fertility with cervical cancer up to stage IB1 [12, 13]. An abdominal cerclage—a circumferential suture placed superior to the excision margin—is usually placed at the conclusion of the procedure, in preparation for pregnancy.
Overall, complication rates are similar between radical trachelectomy and radical hysterectomy, as are oncologic recurrence rates [14]. However, the remaining uterus and presence of cerclage can present distinct challenges postoperatively. Patients who have undergone trachelectomy can develop cervical stenosis, dysmenorrhea with or without hematometra, and vaginal discharge.
Ovarian Cancer Cytoreduction
The standard of care for staging and treatment of ovarian, fallopian tube, and peritoneal cancers includes total hysterectomy with bilateral salpingo-oophorectomy, omentectomy, cytology of the pelvic fluid and diaphragm, and resection of all gross disease. Removal of lymph nodes may be indicated for complete staging or if lymph nodes are grossly enlarged. Patients with extensive disease by imaging or who are poor surgical candidates may receive neoadjuvant chemotherapy—usually three cycles of a platinum and taxane-based chemotherapy regimen—prior to surgery [15, 16]. If possible, any obvious tumor implants are removed, known as cytoreduction. Complete cytoreduction (removal of any visible disease) is associated with the greatest survival advantage but may not always be feasible, while optimal cytoreductio n refers to residual tumor implants less than 1 centimeter (cm) in diameter, and suboptimal cytoreduction leaves tumor implants greater than 1 cm in diameter [17, 18]. These procedures can be associated with significant morbidity depending on the invasiveness and extent of surgery required, particularly in patients with more comorbidities or advanced age [19].
Pelvic Exenteration
Complete pelvic exenteration is a radical procedure involving the removal of the female reproductive organs, lower urinary tract, and/or anus and portion of the rectosigmoid colon. The urinary and gastrointestinal tracts may be diverted to a urostomy and colostomy, respectively. A complete pelvic exenteration also involves removal of the musculature of the pelvic floor and the soft tissue structures of the perineum. An anterior or posterior exenteration with preservation of the uninvolved pelvic organs may also be performed. Reconstruction can be vast and challenging, and the team performing a pelvic exenteration often includes multiple surgical subspecialties, including gynecologic oncology, colorectal surgery, urology and plastic surgery. Pelvic exenteration is offered only as an attempt to cure women with centrally located tumors (usually vulvar or cervical cancer), without evidence of metastatic disease [20]. Rarely, a pelvic exenteration may also be performed for palliation of unmanageable symptoms including pain, bleeding, or fistulae [21].
Given the extent and complexity of these surgeries, patients often require ICU-level care postoperatively. They often have high-volume blood loss intraoperatively, requiring significant resuscitation. Frequent labs (including complete blood counts, coagulation studies and electrolytes) are important monitoring tools. Drains are often left in place to avoid fluid collections and monitor bleeding or anastomotic leak; the volume and appearance of the drain output should be monitored postoperatively. Please refer to the “Diagnosis” section, under “Fever,” for further discussion of assessment of drain output.
Up to 50 % of women will have a major complication after a pelvic exenteration [22]. Early complications include hemorrhage (both intraoperative and delayed), infection, wound breakdown, ileus, anastomotic leak (urinary or bowel), and decline in body image [20]. Late complications include fistula (urinary or bowel), and chronic failure of wound healing. In the delayed postoperative period, it is important to consider the possibility of recurrent cancer. Please see the following section for management of reconstructive flaps.
Vulvectomy
Vulvar lesions can be treated with multiple different modalities, including laser (to vaporize the layer of abnormal cells, not used to treat invasive cancer), topical immunomodulators (also not used to treat invasive cancer), and excision. The type and extent of excision, with or without inguinal lymph node dissection, is highly dependent on the size and location of the lesion [23]. Following radical resections, reconstruction may be required using skin grafts or flaps [24].
Postoperative management after vulvectomy is highly dependent on the extent and location of resection. Patients may have drains in place, particularly following lymphadenectomy; the color and volume of drain output should be closely monitored. In patients with wound reconstruction, strict movement limitations (bed rest and no sitting) are often imposed to preserve the integrity and blood supply of the flap; adequate thromboembolism prophylaxis should be provided during this period of immobility [25]. Vulvar flaps should be assessed regularly, noting color (pale versus congested) and edema. Vulvar incisions must be monitored closely and cleaned frequently, usually with sterile saline or sitz baths.
The most common complication following vulvectomy is wound breakdown, occurring in approximately 15 % of cases [26]. Wound breakdown can predispose the patient to more serious complications, including infection ranging from cellulitis to necrotizing fasciitis. Please refer to Chap. 16, Complications of Minimally Invasive Gynecologic Surgery for the diagnosis and management of postoperative infections. There is also a risk of flap loss if arterial supply or venous drainage is compromised, which may require reoperation.
Lymphadenectomy
Removal of lymph nodes is performed when the risk of metastasis to lymphatic channels is high, determined according to specific criteria for each type of gynecologic cancer. Complications of lymphadenecto my include lymphedema (swelling) and nerve damage; the latter is discussed in Chap. 16, Complications of Minimally Invasive Gynecologic Surgery [27–29]. An extremity with lymphedema must be monitored closely for ulceration and cellulitis.
Chemotherapy
Chemotherapeutic agents for treatment of gynecologic cancers are associated with a range of toxicities, which is beyond the scope of this chapter. Chemotherapeutic drugs commonly encountered in the care of gynecologic oncology patients include platinum-based therapies (cisplatin and carboplatin) and taxanes (paclitaxel); toxicities of these include but are not limited to myelosuppression, nephrotoxicity, and peripheral neuropathy. Gastrointestinal toxicity (nausea and vomiting, in particular) is the most common chemotherapeutic toxicity; please refer to Chap. 14, Common Postoperative and Inpatient issues for more information for more information on the management of nausea.
Acute, severe complications of chemotherapy can occur. Patients may develop acute allergic reactions to any chemotherapy, which may be evidenced by diffuse rash, erythema, respiratory compromise, and/or hypotension. Hypersensitivity reactions to taxanes usually occur with the first or second infusions, while reactions to platinum-based chemotherapy may begin following repeated exposures due to priming of the immune response [30]. Please see Chap. 15, High-Acuity Postoperative and Inpatient Issues and Inpatient Issues, for more information on the diagnosis and management of anaphylaxis. Of note, bevacizumab, a vascular endothelial growth factor (VEGF) inhibitor that is FDA approved for the treatment of recurrent ovarian cancer and metastatic cervical cancer, carries a risk of spontaneous bowel perforation of 0.9 %, associated with a mortality rate of 21.7 % [31]. Bevacizumab may also cause malignant hypertension or wound breakdown.
Definitions
Neutropenic Fever
Neutropenic fever is a single oral temperature of 38.3 C (101 F) or more, or a temperature of 38.0 C (100.4 F) or more sustained for at least 1 h, in a patient with neutropenia [32]. Neutropenia is defined as an absolute neutrophil count (ANC ) less than 1,500 neutrophils/microliter (μL), and severe neutropenia is usually defined as an ANC less than 500 neutrophils/μL or an ANC that is expected to decrease to less than 500 neutrophils/μL over the next 48 h [32]. If not reported by the laboratory, ANC can be calculated by multiplying the total white blood cell (WBC) count by the fraction of polymorphonuclear cells (PMNs) and bands. Common pathogens in neutropenic fever include gram-positive species such as coagulase-negative staphylococci, Staphylococcus aureus, Enterococcus species, the Viridans group streptococci, Streptococcus pneumonia and S. pyogenes, and gram-negative species including Escherichia coli, Klebsiella species, Enterobacter, Citrobacter, Acinetobacter, and Pseudomonas aeruginosa [32].
Tumor Fever
The mechanism is poorly understood and likely related to alterations in cytokines. While non-gynecologic malignancies are more commonly associated with fevers—including leukemia, lymphoma, and renal cell carcinoma—any malignancy can be considered as a cause of fever; fever may be more common in patients with sarcoma and liver metastases [33]. Attribution of fevers to tumor burden is a diagnosis of exclusion; in patients with hemodynamic changes, the diagnosis of tumor fever should be questioned and other alternatives pursued [34, 35].
Bowel Resection
Bowel resection is removal of a part of the bowel (small bowel, large bowel, or both), repaired with either primary reanastomosis (reattachment of healthy proximal and distal portions of bowel) or diversion of the gastrointestinal tract through the abdominal wall; the exposed portion of bowel at the skin is called the stoma. Ileostomy refers to a stoma created by bringing the ileum through the abdominal wall, while a colostomy involves the colon. Complications of stomas include stomal necrosis, stenosis, retraction, prolapse, and parastomal hernia formation, none of which generally require emergent intervention [36]. Complications of bowel reanastomosis include ileus, anastomotic strictures, leaks, and bowel obstruction, discussed under Management.
Bowel Obstruction
Bowel obstruction is mechanical blockade of normal bowel peristalsis, occurring most commonly in the small bowel; small bowel obstruction is discussed in Chap. 16, Complications of Minimally Invasive Gynecologic Surgery. Large bowel obstruction accounts for up to 25 % of all intestinal obstructions, and approximately 70 % of large bowel obstructions occur at or distal to the transverse colon [37]. Risk factors for bowel obstruction postoperatively include intraoperative lysis of adhesions and/or concomitant bowel surgery, blood transfusion, and cystotomy [38]. Specific to gynecologic oncology, risk factors include extensive disease burden, particularly tumor causing extrinsic bowel compression, or radiation therapy.
Abdominal Wound Separation
Fascial dehiscence refers to the separation of the fascia, usually occurring 3–7 days postoperatively, in up to 1.2 % of laparotomies [39, 40]. Fascial dehiscence is a surgical emergency, associated with a high mortality rate of up to 24 % [41]. Risk factors include wound infection, sepsis, age over 65 years, the presence of an ostomy within the incision, hypoproteinemia, poor nutrition, pulmonary disease, hypertension, obesity, and steroid use [42]. Superficial wound separation, involving just the suprafascial layers, may also occur and usually represents a far more mild complication. Please refer to Chap. 16, Complications of Minimal Invasive Gynecologic Surgery, for the diagnosis and management of vaginal cuff dehiscence.
Differential Diagnosis by Primary Complaint
Fever
· Superficial surgical site infection
· Vaginal cuff cellulitis
· Pelvic hematoma or abscess
· Cystitis
· Pyelonephritis
· Clostridium difficile colitis
· Retained foreign bodyToxic shock syndrome
· Necrotizing fasciitis
· Septic pelvic thrombophlebitis
· Ovarian vein thrombosis
· Deep vein thrombosis (DVT)
· Pulmonary embolism (PE)
· Pneumonia
· Medication effect (drug fever)
· Tumor fever
· Neutropenic fever
· Pancreatic leak following pancreatic resection or splenectomy
· Urinary tract injury
· Bowel perforation, injury or anastomotic leak
· Alcohol withdrawal
· Transfusion reaction (hemolytic, febrile non-hemolytic, and Transfusion-Related Acute Lung Injury)
Pain
· Bowel injury
· Small or large bowel obstruction
· Bowel anastomotic stricture
· Bowel anastomotic leak
· Urinary tract injury
· Pancreatic leak following pancreatic resection or splenectomy
· Cystitis
· Pyelonephritis
· Superficial surgical site infection
· Vaginal cuff cellulitis
· Pelvic hematoma or abscess
· Ovarian vein thrombosis
· Necrotizing fasciitis
· Vaginal cuff dehiscence
· Abdominal wound dehiscence
· Urine retention
· Inadequate analgesic medications
· Oncologic pain (tumor burden)
Nausea/Vomiting
· Ileus
· Small or large bowel obstruction
· Bowel injury
· Bowel incarceration due to an incisional or peristomal hernia, stoma retraction, or prolapse
· Bowel anastomotic stricture
· Bowel anastomotic leak
· Pancreatic leak following pancreatic resection or splenectomy
· Urinary tract injury (particularly urinary ascites causing ileus)
· Chemotherapy-related nausea
· Medication effects (including anesthetics and narcotics)
· Nonsurgery related (i.e., viral gastroenteritis)
Vaginal Hemorrhage
· Bleeding due to tumor will be addressed in this chapter. Please see Chap. 2, Vaginal Hemorrhage, for alternative diagnoses.
As with any gynecologic surgeries, risks of oncologic surgery include infectious, vascular, urologic, gastrointestinal, and nerve injuries or complications; please see Chap. 16, Complications of Minimally Invasive Gynecologic Surgery, for more information. Unique to surgical intervention for gynecologic cancer, procedures such as splenectomy, bowel resection, and pancreatectomy may be required, each with unique considerations and complications [43, 44].
When You Get the Call
Ask for the most recent set of vital signs . Ensure that basic labs (such as a complete metabolic panel, complete blood count, and coagulation studies) have been ordered in clinically ill or unstable patients and at least one IV has been placed. Consider ordering an electrocardiogram (ECG) and chest radiograph while in route to see the patient as clinically indicated.
When You Arrive
Review the full vital sign flow sheet, noting whether the patient is febrile, tachycardia, hypotensive, or tachypneic. In addition, in an oncologic patient, it is important to review the patient’s cancer type, stage, and any prior treatments (radiation, chemotherapy, surgery). If the patient is postoperative, review the operative report for the extent of dissection, and whether any bowel injury or resection occurred.
History
Review with the patient when her primary symptoms began and any associated symptoms, including but not limited to fever, abdominal distention, nausea, vomiting, or diarrhea. In patients with nausea or vomiting, ask about recent flatus or bowel movements, the absence of which may be concerning for bowel obstruction. If the patient is presenting with vaginal bleeding or discharge or abdominal pain, review her activities at the time of symptom onset, including heavy lifting or intercourse, which, within 6-8 weeks of total hysterectomy (and sometimes longer), may predispose to vaginal cuff dehiscence.
Review the patient’s full medical history, including any chronic diseases such as diabetes or a history of venous thromboembolism . Make note of any current medications, including anticoagulant therapy and chronic steroid use. Review whether the patient has received hematopoietic growth factors —such as granulocyte-macrophage colony-stimulating factor (GM-CSF) or granulocyte colony-stimulating factor (G-CSF)—which are used for prophylaxis against febrile neutropenia resulting from chemotherapy and may result in leukocytosis. Dexamethasone is often given during chemotherapy and may also cause leukocytosis and hyperglycemia. Review her prior surgical history, as prior surgeries may increase the risk of adhesions and intraoperative injury to other organs.
A complete oncologic history includes the date of diagnosis, primary tumor site, stage, grade, and histology, and initial presenting symptoms at diagnosis, as well as the dates and nature of any subsequent treatments, including chemotherapy, radiation, and surgical treatments. Be sure to note any recurrences or complications during the patient’s treatment course. Note the plan for any further treatments, such as upcoming chemotherapy or radiation treatments.
Physical Examination
Assess whether the patient is alert and oriented, and whether she is in distress (visibly uncomfortable, pale, diaphoretic or tachypneic). Check for capillary refill by pressing on the fingernails; delayed reperfusion of the nail beds is evidence of decreased perfusion, associated with sepsis or anemia. Perform a complete physical exam, including examination of the heart, lungs, abdomen (noting distention, a fluid wave due to ascites, rebound, or involuntary guarding, and assessing any surgical incisions, drains, and ostomies), and the lower extremities (noting edema, and asymmetrical swelling or tenderness). Particularly in patients with fever or sepsis, assess for sacral decubitus ulcers in chronically ill or immobile patients, and any other skin disruption. Assess percutaneous nephrostomy tubes (for urinary diversion), subcutaneous ports (for central venous or peritoneal access), peripherally inserted central catheters (PICCs), and any other indwelling catheters for evidence of thrombophlebitis or abscess. In patients with bleeding, a physical examination is required to determine the source of bleeding—including uterine, cervical, vaginal, vulvar, or rectal sources—and to assess for the presence of any obvious tumor. Oncologic patients often have more complex histories and comorbidities, so it may be necessary to complete further portions of the physical exam as well (such as a neurologic exam in patients with altered mental status or musculoskeletal exam in patients presenting with pain).
In postoperative patients with abdominal pain or fever, and surgical wounds with erythema or drainage, the skin should be opened to release any collections (seroma, hematoma, or purulence), and the fascia should be probed with a sterile cotton swab to assess for dehiscence [48]. If a patient has drains or a vacuum-assisted wound closure device, assess the output for increased volume, blood, purulence or any other concerning changes. In patients with postoperative drains in place, Jackson-Pratt drains are among the most common closed systems; these consist of thin plastic tubing placed through the abdominal wall, usually sutured into place, and connected to a small reservoir outside, which is attached in a collapsed position to generate suction. Review the drain location (near certain organs or anastomoses intra-abdominally, or in the subcutaneous tissue). Drains may be placed near bowel anastomoses, cystotomy repairs or pancreatic resections because drain output can provide evidence of a leak; hemorrhage may also be revealed in drain output.
Diagnosis
Fever
Postoperatively, a temperature of 100.4 F (38 C) on two occasions more than 4 h apart, or a single temperature of 101 F (38.3 C), constitutes a fever [45]. In a patient with neutropenia, neutropenic fever is defined as a single oral temperature of 38.3 C (101 F) or more, or a temperature of 38.0 C (100.4 F) or more sustained for at least 1 h [32]. Always assess for physiologic or laboratory findings suggestive of sepsis (Table 18.1), which requires rapid intervention [46, 47].
Table 18.1
Clinical criteria of sepsis and severe sepsis
|
Sepsis |
Severe sepsis |
|
Suspected source plus 2 or more: 1. Temperature >38.3 C (101 F) or <36 C (96.8 F) 2. Heart rate >90 beats per min 3. Tachypnea (>20 breaths/min) 4. WBC >12,000 μ/L or <4000 μ/L or normal with >10 % immature (band) forms |
Sepsis plus one or more: 1. Systolic blood pressure <90 mmHg or decrease from baseline by 40 mmHg 2. Elevated lactate (>1 mmol/L; >4 particularly concerning, sign of organ hypoperfusion) 3. Acute lung injury: PaO2/FIO2 < 250 (in the absence of pneumonia) or <200 (with pneumonia) 4. Acute oliguria: <0.5 mL/kg/h despite fluid resuscitation 5. Creatinine >2 mg/dL 6. INR > 1.5 7. Platelets <100,000/uL 8. Bilirubin >2 mg/dL |
Adapted from Dellinger et al. [46] and Fischerova [47]
The differential diagnosis for fever depends on the patient’s recent treatment, and, if applicable, her interval from surgery. Fevers in the first 24 h after surgery are typically noninfectious, due to inflammation or medication reactions [48]. Infectious complications usually present beyond 48 h after surgery. Pneumonia (particularly aspiration) and urinary tract infections may present as early as the first 2-3 days postoperatively, while the presentation of surgical site infections, vaginal cuff complications and pelvic abscesses commonly may be delayed by 5 or more days. Bowel and urinary tract injuries typically present in the days following surgery, but may be delayed by 1-2 weeks. Neutropenia (and associated neutropenic fevers) depends on the chemotherapeutic agent and dosing schedule. Thrombosis-associated fever can occur at any time, but fever greater than 101 F is rarely related to thrombosis and should prompt exclusion of infectious etiologies first. Postoperative infections are more common in older patients with immunosuppression, diabetes, obesity, longer operative times (greater than 3 h), and smokers [49].
Laboratory testing should include a complete blood count with a differential, and urinalysis. In patients with a fever of 38.3 C (101 F) or more, obtain blood cultures (including one drawn from any central venous catheter), in addition to a urine culture, and cultures of any purulent wound exudate. Order a stool study for Clostridium difficile (polymerase chain reaction or enzyme immunoassay for microbe or toxin detection) in any patient with diarrhea and recent antibiotic exposure and/or prior Clostridium difficile infection. 1,3 [beta]-d-glucan, mannan, and anti-mannan antibody assays can be obtained in patients taking steroids or those with neutropenia, to assess for disseminated candidiasis. In patients with possible sepsis, check a lactate, liver function tests, electrolytes and creatinine. Also obtain coagulation studies (prothrombin time (PT), activated partial thromboplastin time (aPTT) and fibrinogen) to assess for disseminated intravascular coagulation.
Assess surgical drain output and consider sending laboratory testing, which can provide evidence of a postoperative complication resulting in fever or sepsis. Visual examination of output from a drain near a leaking bowel anastomosis may reveal obvious bowel contents, prompting imaging and/or intervention. Fluid from a drain near the bladder following cystotomy repair or a urinary conduit will have a much higher creatinine level than the serum in the setting of a urine leak (usually several fold higher). Fluid from a drain near a pancreatic or splenic resection may be sent for amylase levels after a patient has resumed a regular diet (and the pancreas is stimulated) to rule out pancreatic leak; drain fluid levels that are triple the serum levels are consistent with pancreatic disruption [50]. If a patient has a chest tube in place, assess the color of the fluid for blood, pus, or chyle (which will separate into fatty layers inside the Pleur-evac® drainage system, Teleflex, Morrisville, NC). Any bubbles in the water seal chamber should also be noted, as these indicate continued passage of air into the pleural space.
Obtain imaging as indicated by the history and physical exam, including chest radiograph, pelvic ultrasound, or abdominal CT scan. Abdominal CT scans are particularly helpful in identifying pelvic hematomas or abscesses, but can also identify other sources of fever and pain, including bowel injury or obstruction, anastomotic leak, and urinary tract injury, while also characterizing tumor burden or progression. Oral and intravenous contrast should be given whenever possible.
Pain
The assessment of patients with gynecologic cancers with pain should be tailored to the acuity of their presentations. Patients with new-onset or postoperative pain should also have a complete blood count to assess for leukocytosis and anemia and a basic metabolic panel to assess for electrolyte derangements and creatinine elevation. A urinalysis may reveal urinary tract infection. Relevant tumor markers can also be sent if disease recurrence or progression is suspected. Abdominal imaging should be obtained, targeted to the suspected source of pain. If the differential diagnosis remains broad, an abdominal CT scan with oral and IV contrast can be helpful, revealing tumor burden, hemorrhage or progression, urinary or gastrointestinal tract injuries or obstructions, pelvic fluid collections (hematoma, abscess, or urinary ascites), thromboses in pelvic vessels, or wound dehiscence [48].
In an oncologic patient with advanced disease, her disease may be the source of her pain—through mechanisms such as tumor invasion or compression of other structures and pathologic bone fractures—though this is a diagnosis of exclusion. Tumor-related pain is not a reason to forgo a full assessment, as many of these sources of pain can be addressed or palliated.
Nausea/Vomiting
In patients with emesis, check a complete metabolic panel to assess for electrolyte and metabolic derangements. In a patient with hypotension, tachycardia, fever, or acute pain on exam, obtain a complete blood count and complete metabolic panel; serum lactate should also be sent, which may be elevated in conditions including (but not limited to) sepsis and bowel ischemia [51]. Relevant tumor markers can also be sent if disease recurrence or progression is suspected. A urinalysis, particularly in postoperative patients, can be sent to assess for infection.
The specificity of abdominal radiographs for the diagnosis of ileus or bowel obstruction is poor, and in patients with prolonged symptoms of ileus or obstruction, an abdominal CT is recommended [52, 53]. On abdominal CT, in patients with postoperative ileus, oral contrast will pass through the entire digestive tract, and the colon will contain air and fluid [54]. In patients with obstruction, a transition point may be identifiable by CT—potentially associated with tumor—with proximally dilated and distally collapsed bowel (Fig. 18.1) [54–58]. Diagnosis of a bowel injury or anastomotic leak is optimally made using abdominal CT with oral contrast, which may extravasate [48, 59].
Fig. 18.1
Small bowel obstruction. (a) Axial image shows dilated loops proximal to decompressed loops, diagnostic of SBO. (b) Coronal reformatted image shows a linear band (arrow) extending toward the dilated loops, representing the adhesive band (Reprinted from Desser and Gross [55], with permission from Elsevier)
Please refer to Chap. 16, Complications of Minimally Invasive Gynecologic Surgery, for the diagnosis and management of ileus, small bowel obstruction, bowel and urinary tract injury.
Bleeding Due to Tumor
Please see Chap. 2, Vaginal Hemorrhage, for more information on diagnosis and initial resuscitation in patients with vaginal hemorrhage. Briefly, a complete blood count, coagulation studies, and blood type and antibody screen should be collected.
Patients with gynecologic malignancy—most commonly cervical, uterine, or gestational trophoblastic neoplasia—may develop bleeding either due to tumor invasion into vascular structures or due to friable tumor blood supply [60]. Of note, radiation can cause mucosal irritation and bleeding, but this would less commonly present as hemorrhage [61].
If a patient with vaginal hemorrhage is sufficiently stable, imaging to evaluate tumor size and location can be helpful, usually performed by CT scan with IV contrast, which may reveal contrast extravasation due to acute bleeding. If tumor is visualized in the cervix, vagina, or vulva by physical exam, specimen removal or biopsy may exacerbate acute hemorrhage. Malignancy-related bleeding is likely to be visible vaginally; hemorrhage of an intra-abdominal tumor is less common, but may be detected by serially declining hemoglobin and evidence of hemorrhage—either hemoperitoneum or enhancement within the tumor consistent with hemorrhage—by pelvic ultrasound or CT scan [62, 63].
Management
Please see Chap. 14, Common Inpatient and Postoperative Issues, for general management of nausea and vomiting.
Fever
In patients with clinical indicators of sepsis, initial management includes the placement of two large-bore IVs and supplemental oxygen by high-flow facemask as needed [46]. If not obtained earlier, a complete blood count and complete metabolic panel including liver function tests, coagulation studies and lactate should be obtained. These labs (as indicated) should be rechecked frequently during resuscitation to assess progress. An arterial blood gas should be obtained in acutely ill patients. Antibiotics should be started within 1 h, and the source of infection must be identified and controlled. Please see Chap. 1, Acute Pelvic Pain, for more information on the management of sepsis.
In patients with central venous catheters with positive blood cultures (for the same organism) from the catheter and peripheral blood, persistent bacteremia after 72 h of antibiotic treatment, sepsis or hemodynamic instability, this catheter should be removed if clinically feasible [64]. Establishing whether a catheter-associated infection is truly present can be challenging, and the removal of long-term catheters (such as ports) is more involved; consider consulting infectious disease specialists. Obtain a culture of the catheter tip for confirmation if the catheter is removed. Following a catheter-related infection, resolution of bacteremia as demonstrated by negative blood cultures for 48 h should precede reinsertion of a new line.
Following Splenectomy
Patients with prior splenectomy are at increased risk for contracting infections with encapsulated bacteria, most commonly Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenza, and Streptococcus pyogenes[65]. When a splenectomy is planned preoperatively, pneumococcal, meningococcal, and H. influenzae vaccinations should be given 2 weeks prior to surgery. In patients with an unanticipated splenectomy, these vaccines should be given 2 weeks after surgery for the highest immunologic response, but from a practical perspective, these vaccines are often given immediately prior to hospital discharge [66].
Neutropenic Fever
Among hemodynamically stable patients presenting with fever, those with neutropenic fever are at greater risk of rapid progression of their infections as compared to immunocompetent patients; recognition and early treatment are crucial to prevention of progression to sepsis. Empiric antibacterial treatment should be initiated as soon as possible following collection of blood cultures [46, 67]. The infectious source must be identified and controlled as quickly as possible; the history, physical examination, and targeted imaging may identify the source.
Patients with neutropenic fever are stratified according to risk; high-risk patients are those with anticipated prolonged (greater than 7 days) or profound neutropenia (ANC less than 100 neutrophils/μL), or those with significant clinical illness, including identified infectious source, hypotension, hypoxemia, electrolyte abnormalities, nausea, emesis, diarrhea, significant pain, dehydration, chronic cardiopulmonary or renal disease, and those age > 60 years [32, 67]. Low-risk patients are those with anticipated brief neutropenic period (less than 7 days) and minimal clinical symptoms and comorbidities.
High-risk patients should be admitted immediately for empiric antibiotic therapy, whereas low-risk patients may be candidates for oral empiric therapy [32]. Intravenous empiric antibiotics include an antipseudomonal beta-lactam agent (such as cefepime 2 g IV every 8 h, meropenem 1 g IV every 8 h, or piperacillin-tazobactam 4.5 g IV every 6–8 h). Addition of further antimicrobials (vancomycin, an aminoglycoside, or fluoroquinolone) for broader coverage should be considered if microbial resistance is suspected or the patient is hemodynamically unstable. In particular, consider the addition of vancomycin in patients with skin or soft tissue infections, catheter- or drain-related infection, or ongoing hemodynamic instability.
Per the Infectious Diseases Society of America (IDSA) guidelines, a low-risk patient can be considered for an oral regimen. Initial regimens include ciprofloxacin (750 mg PO every 12 h) plus amoxicillin-clavulanate (500 mg/125 mg PO every 8 h), or ciprofloxacin plus clindamycin though the latter regimen is less well studied. Close outpatient follow-up is vital in these patients [32].
Large Bowel Obstruction
Patients with large bowel obstruction may report a longer duration of symptoms and less nausea and emesis than patients with small bowel obstruction, as the ileocecal valve provides an anatomic proximal point of dilation; severe large bowel obstructions will overwhelm the ileocecal valve and small bowel may become dilated as well [56, 58].
Unlike small bowel obstructions, for which conservative management is preferred, over 75 % of large bowel obstructions require surgical intervention [37]. Complete large bowel obstruction is a surgical emergency regardless of etiology, as perforation can lead to acute peritonitis and severe sepsis. Placement of a nasogastric tube may improve symptoms of nausea and emesis, but is insufficient treatment for a large bowel obstruction. A potential alternative to surgical management in carefully selected patients is the placement of a colonic stent, which can sometimes be used as a bridge to surgery if preoperative stabilization is required, or as palliation in nonoperative candidates or patients with advanced disease [68].
Anastomotic Leak
Anastomotic leaks should be considered as surgical emergencies, though treatment may vary somewhat depending on the clinical severity. All patients diagnosed with anastomotic leak should be started on broad-spectrum antibiotics (such as piperacillin-tazobactam 4.5 g IV every 8 h) and placed on bowel rest [44, 69]. Patients presenting with evidence of peritonitis, severe sepsis, and/or hemodynamic stability require resuscitation and emergent exploratory laparotomy [70]. In a small subset of patients with localized peritonitis and/or evidence of mild infection only, a contained leak or abscess may potentially be managed with intravenous antibiotics and drainage by interventional radiology [70].
Abdominal Wound Separation
Fascial dehiscence is a surgical emergency, requiring immediate reoperation and repair. Conversely, superficially separated wounds with intact fascia can be managed with serial debridement of necrotic tissue and wet-to-dry dressings 2–3 times per day; wounds may heal by secondary intention or with placement of a negative pressure dressing (once any infection has been resolved) [71]. Alternatively, wounds can be surgically reclosed once healthy granulation tissue has formed, without evidence of ongoing infection [48, 72]. Vaginal cuff dehiscence is discussed in Chap. 16, Complications of Minimally Invasive Gynecologic Surgery.
Bleeding Due to Tumor
Significant vaginal hemorrhage due to cervical malignancy requires emergent radiation oncology consultation; hemorrhage from a uterine tumor can be treated with emergent radiation, emergent embolism by interventional radiology, or emergent surgical intervention, including hysterectomy or other tumor resection [73, 74]. The decision among these modalities depends on which resources and clinicians are available emergently, the patient’s stability (as interventional radiology and radiation therapy require time for resource mobilization), and the patient’s comorbid conditions and/or functional capacity, which may limit her eligibility for invasive surgery.
Hemorrhage within pelvic tumors and spontaneous hemoperitoneum are less uncommon in patients with gynecologic malignancies [75, 76]. Patients who are hemodynamically stable with stable hemoglobin levels may not require further intervention . Those with declining hemoglobin and/or hemodynamic instability may require embolization or operative management, depending on the source of the bleeding and the patient’s clinical stability, treatment goals, and functional capacity [60].
Please see Chap. 13, Preparing for Urgent or Emergent Surgery, for more information on transfusion of patients with hemorrhage and anticoagulation reversal, as needed.
References
1.
Howlader N, Noone AM, Krapcho M, Garshell J, Miller D, Altekruse SF, et al., editors. SEER cancer statistics review, 1975-2012, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2012/, based on November 2014 SEER data submission, posted to the SEER web site, April 2015. Accessed 25 July 2015
2.
Finch A, Beiner M, Lubinski J, Lynch HT, Moller P, Rosen B, et al. Salpingo-oophorectomy and the risk of ovarian, fallopian tube, and peritoneal cancers in women with a BRCA1or BRCA2 Mutation. JAMA. 2006;296:185–92.CrossRefPubMed
3.
Martin-Hirsch PL, Wood NJ. Cervical cancer. Am Fam Physician. 2012;85:1186–7.
4.
Williams NL, Werner TL, Jarboe EA, Gaffney DK. Adenocarcinoma of the cervix: should we treat it differently? Curr Oncol Rep. 2015;17:17.
5.
Hoffman BL, Schorge JO, Schaffer JI, Halvorson LM, Bradshaw KD, Cunningham F, et al. Chapter 33. Endometrial cancer. In: Hoffman BL, Schorge JO, Schaffer JI, Halvorson LM, Bradshaw KD, Cunningham F, et al. editors. Williams gynecology, 2edn. New York: McGraw-Hill; 2012. http://accessmedicine.mhmedical.com.ezp-prod1.hul.harvard.edu/content.aspx?bookid=399&Sectionid=41722324. Accessed 06 Sept 2015.
6.
Canavan TP, Cohen D. Vulvar cancer. Am Fam Physician. 2002;66:1269–74.PubMed
7.
American Cancer Society. Cancer facts & figures 2015. Atlanta: American Cancer Society; 2015. http://www.cancer.org/acs/groups/content/@editorial/documents/document/acspc-044552.pdf. Accessed 6 Sept 2015.
8.
Beller U, Benedet JL, Creasman WT, Ngan HY, Quinn MA, Maisonneuve P, et al. Carcinoma of the vagina. FIGO 26th annual report on the results of treatment in gynecological cancer. Int J Gynaecol Obstet. 2006;95:S29–42.CrossRefPubMed
9.
Semer DA, Macfee MS. Gestational trophoblastic disease: epidemiology. Semin Oncol. 1995;22:109–12.PubMed
10.
Altieri A, Franceschi S, Ferlay J, Smith J, La Vecchia C. Epidemiology and aetiology of gestational trophoblastic diseases. Lancet Oncol. 2003;4:670–8.CrossRefPubMed
11.
Zullo MA, Manci N, Angioli R, Muzii L, Panici PB. Vesical dysfunctions after radical hysterectomy for cervical cancer: a critical review. Crit Rev Oncol Hematol. 2003;48:287–93.CrossRefPubMed
12.
Roy M, Plante M. Pregnancies after radical vaginal trachelectomy for early-stage cervical cancer. Am J Obstet Gynecol. 1998;179:1491–6.CrossRefPubMed
13.
Sahdev A, Sohaib SA, Wenaden AE, Shepherd JH, Reznek RH. The performance of magnetic resonance imaging in early cervical carcinoma: a long-term experience. Int J Gynecol Cancer. 2007;17:629–36.CrossRefPubMed
14.
Marchiole P, Benchaib M, Buenerd A, Lazlo E, Dargent D, Mathevet P. Oncological safety of laparoscopic-assisted vaginal radical trachelectomy (LARVT or Dargent’s operation): a comparative study with laparoscopic-assisted vaginal radical hysterectomy (LARVH). Gynecol Oncol. 2007;106:132–41.CrossRefPubMed
15.
Vergote I, Tropé CG, Amant F, Kristensen GB, Ehlen T, Johnson N, et al. Neoadjuvant chemotherapy or primary surgery in stage IIIC or IV ovarian cancer. N Engl J Med. 2010;363:943–53.CrossRefPubMed
16.
Kehoe S, Hook J, Nankivell M, Jayson GC, Kitchener H, Lopes T, et al. Primary chemotherapy versus primary surgery for newly diagnosed advanced ovarian cancer (CHORUS): an open-label, randomised, controlled, non-inferiority trial. Lancet. 2015;386:249–57.CrossRefPubMed
17.
Chang SJ, Hodeib M, Chang J, Bristow RE. Survival impact of complete cytoreduction to no gross residual disease for advanced-stage ovarian cancer: a meta-analysis. Gynecol Oncol. 2013;130:493–8.CrossRefPubMed
18.
Elattar A, Bryant A, Winter-Roach BA, Hatem M, Naik R. Optimal primary surgical treatment for advanced epithelial ovarian cancer. Cochrane Database Syst Rev. 2011;(8):CD007565.
19.
Wright JD, Herzog TJ, Neugut AI, Burke WM, Lu YS, Lewin SN, et al. Effect of radical cytoreductive surgery on omission and delay of chemotherapy for advanced-stage ovarian cancer. Obstet Gynecol. 2012;120:871–81.CrossRefPubMed
20.
Marnitz S, Köhler C, Müller M, Behrens K, Hasenbein K, Schneider A. Indications for primary and secondary exenterations in patients with cervical cancer. Gynecol Oncol. 2006;103:1023–30.CrossRefPubMed
21.
Stanhope CR, Symmonds RE. Palliative exenteration – what, when, and why? Am J Obstet Gynecol. 1985;152:12–6.CrossRefPubMed
22.
Höckel M, Dornhöfer N. Pelvic exenteration for gynaecological tumours: achievements and unanswered questions. Lancet Oncol. 2006;7:837–47.CrossRefPubMed
23.
De Hullu JA, Hollema H, Lolkema S, Boezen M, Boonstra H, Burger MP. Vulvar carcinoma. The price of less radical surgery. Cancer. 2002;95:2331–8.CrossRefPubMed
24.
Aviki EM, Esselen KM, Barcia SM, Nucci MR, Horowitz NS, Feltmate CM, et al. Does plastic surgical consultation improve the outcome of patients undergoing radical vulvectomy for squamous cell carcinoma of the vulva? Gynecol Oncol. 2015;137:60–5.CrossRefPubMed
25.
Salgarello M, Farallo E, Barone-Adesi L, Cervelli D, Scambia G, Salerno G, et al. Flap algorithm in vulvar reconstruction after radical, extensive vulvectomy. Ann Plast Surg. 2005;54:184–90.CrossRefPubMed
26.
Argenta PA, Lindsay R, Aldridge RB, Siddiqui N, Burton K, Telfer JR. Vulvar reconstruction using the “lotus petal” fascio-cutaneous flap. Gynecol Oncol. 2013;131:726–9.CrossRefPubMed
27.
Abu-Rustum NR, Alektiar K, Iasonos A, Lev G, Sonoda Y, Aghajanian C, et al. The incidence of symptomatic lower-extremity lymphedema following treatment of uterine corpus malignancies: a 12-year experience at Memorial Sloan-Kettering Cancer Center. Gynecol Oncol. 2006;103:714–8.CrossRefPubMed
28.
Gaarenstroom KN, Kenter GG, Trimbos JB, Agous I, Amant F, Peters AA, Vergote I. Postoperative complications after vulvectomy and inguinofemoral lymphadenectomy using separate groin incisions. Int J Gynecol Cancer. 2003;13:522–7.CrossRefPubMed
29.
Rockson SG. Diagnosis and management of lymphatic vascular disease. J Am Coll Cardiol. 2008;52:799–806.CrossRefPubMed
30.
Lenz HJ. Management and preparedness for infusion and hypersensitivity reactions. Oncologist. 2007;12:601–9.CrossRefPubMed
31.
Hapani S, Chu D, Wu S. Risk of gastrointestinal perforation in patients with cancer treated with bevacizumab: a meta-analysis. Lancet Oncol. 2009;10:559–68.CrossRefPubMed
32.
Freifeld AG, Bow EJ, Sepkowitz KA, Boeckh MJ, Ito JI, Mullen CA, et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America. Clin Infect Dis. 2011;52:e56–93.CrossRefPubMed
33.
Bodel P. Generalized perturbations in host physiology caused by localized tumors. Tumors and fever. Ann N Y Acad Sci. 1974;230:6–13.CrossRefPubMed
34.
Kurzrock R. The role of cytokines in cancer-related fatigue. Cancer. 2001;92:1684–8.CrossRefPubMed
35.
Zell JA, Chang JC. Neoplastic fever: a neglected paraneoplastic syndrome. Support Care Cancer. 2005;13:870–7.CrossRefPubMed
36.
Colwell J. Stomal and peristomal complications. In: Colwell J, Goldberg M, Carmel J, editors. Fecal and urinary diversions: management principles. St. Louis: Mosby; 2004.
37.
Markogiannakis H, Messaris E, Dardamanis D, Pararas N, Tzertzemelis D, Giannopoulos P, et al. Acute mechanical bowel obstruction: clinical presentation, etiology, management and outcome. World J Gastroenterol. 2007;13:432–7.CrossRefPubMedPubMedCentral
38.
Antosh DD, Grimes CL, Smith AL, Friedman S, McFadden BL, Crisp CC, et al. A case–control study of risk factors for ileus and bowel obstruction following benign gynecologic surgery. Int J Gynaecol Obstet. 2013;122:108–11.CrossRefPubMed
39.
Cliby WA. Abdominal incision wound breakdown. Clin Obstet Gynecol. 2002;45:507–17.CrossRefPubMed
40.
Carlson MA. Acute wound failure. Surg Clin North Am. 1997;77:607–36.CrossRefPubMed
41.
Madsen G, Fischer L, Wara P. Burst abdomen – clinical features and factors influencing mortality. Dan Med Bull. 1992;39:183–5.PubMed
42.
Riou JP, Cohen JR, Johnson Jr H. Factors influencing wound dehiscence. Am J Surg. 1992;163:324–32.CrossRefPubMed
43.
Eisenkop SM, Spirtos NM, Lin WC. Splenectomy in the context of primary cytoreductive operations for advanced epithelial ovarian cancer. Gynecol Oncol. 2006;100:344–8.CrossRefPubMed
44.
Magtibay PM, Adams PB, Silverman MB, Cha SS, Podratz KC. Splenectomy as part of cytoreductive surgery in ovarian cancer. Gynecol Oncol. 2006;102:369–74.CrossRefPubMed
45.
Faro C, Faro S. Postoperative pelvic infections. Infect Dis Clin North Am. 2008;22:653–63.CrossRefPubMed
46.
Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med. 2013;41:580–637.CrossRefPubMed
47.
Fischerova D. Urgent care in gynaecology: resuscitation and management of sepsis and acute blood loss. Best Pract Res Clin Obstet Gynaecol. 2009;23:679–90.CrossRefPubMed
48.
Clarke-Pearson DL, Geller EJ. Complications of hysterectomy. Obstet Gynecol. 2013;121:654–73.CrossRefPubMed
49.
Beilman GJ, Dunn DL, Beilman GJ, Dunn DL, Beilman, Greg J, David L. Dunn. Surgical infections. In: Brunicardi F, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, et al. editors. Schwartz’s principles of surgery, 10 edn. New York: McGraw-Hill; 2014. http://accessmedicine.mhmedical.com.ezp-prod1.hul.harvard.edu/content.aspx?bookid=980&Sectionid=59610847. Accessed 11 June 2015.
50.
Bassi C, Dervenis C, Butturini G, Fingerhut A, Yeo C, Izbicki J, et al. Postoperative pancreatic fistula: an international study group (ISGPF) definition. Surgery. 2005;138:8–13.CrossRefPubMed
51.
Lange H, Jäckel R. Usefulness of plasma lactate concentration in the diagnosis of acute abdominal disease. Eur J Surg. 1994;160:381.PubMed
52.
Megibow AJ. Bowel obstruction. Evaluation with CT. Radiol Clin North Am. 1994;32:861–70.PubMed
53.
Heinberg EM, Finan MA, Chambers RB, Bazzett LB, Kline RC. Postoperative ileus on a gynecologic oncology service – do abdominal X-rays have a role? Gynecol Oncol. 2003;90:158–62.CrossRefPubMed
54.
Frager DH, Baer JW, Rothpearl A, Bossart PA. Distinction between postoperative ileus and mechanical small-bowel obstruction: value of CT compared with clinical and other radiographic findings. AJR Am J Roentgenol. 1995;164:891–4.
55.
Desser TS, Gross M. Multidetector row computed tomography of small bowel obstruction. Semin Ultrasound CT MR. 2008;29:308–21.CrossRefPubMed
56.
Hayakawa K, Tanikake M, Yoshida S, Urata Y, Inada Y, Narumi Y, et al. Radiological diagnosis of large-bowel obstruction: nonneoplastic etiology. Jpn J Radiol. 2012;30:541–52.CrossRefPubMed
57.
Gerhardt RT, Nelson BK, Keenan S, Kernan L, MacKersie A, Lane MS. Derivation of a clinical guideline for the assessment of nonspecific abdominal pain: the Guideline for Abdominal Pain in the ED Setting (GAPEDS) Phase 1 Study. Am J Emerg Med. 2005;23:709–17.CrossRefPubMed
58.
Frager D, Rovno HD, Baer JW, Bashist B, Friedman M. Prospective evaluation of colonic obstruction with computed tomography. Abdom Imaging. 1998;23:141–6.CrossRefPubMed
59.
Gjelsteen AC, Ching BH, Meyermann MW, Prager DA, Murphy TF, Berkey BD, et al. CT, MRI, PET, PET/CT, and ultrasound in the evaluation of obstetric and gynecologic patients. Surg Clin North Am. 2008;88:361–90.CrossRefPubMed
60.
Bosscher MR, van Leeuwen BL, Hoekstra HJ. Surgical emergencies in oncology. Cancer Treat Rev. 2014;40:1028–36.CrossRefPubMed
61.
Kirchheiner K, Nout RA, Tanderup K, Lindegaard JC, Westerveld H, Haie-Meder C, et al. Manifestation pattern of early-late vaginal morbidity after definitive radiation (chemo) therapy and image-guided adaptive brachytherapy for locally advanced cervical cancer: an analysis from the EMBRACE study. Int J Radiat Oncol Biol Phys. 2014;89:88–95.CrossRefPubMed
62.
Geisler JP, Denman BJ, Cudahy TJ, Lee TH, Geisler HE. Ovarian carcinoma presenting as intra-abdominal hemorrhage. Gynecol Oncol. 1994;53:380–1.CrossRefPubMed
63.
La Fianza A, Cassani C, Ori Belometti G. Intralesional hemorrhage in Krukenberg tumor: a case report and review of the literature. J Ultrasound. 2013;16:89–91.CrossRefPubMedPubMedCentral
64.
Mermel LA, Allon M, Bouza E, Craven DE, Flynn P, O’Grady NP, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-related infection: 2009 Update by the Infectious Diseases Society of America. Clin Infect Dis. 2009;49:1–45.
65.
Okabayashi T, Hanazaki K. Overwhelming postsplenectomy infection syndrome in adults – a clinically preventable disease. World J Gastroenterol. 2008;14:176–9.
66.
Rubin LG, Levin MJ, Ljungman P, Davies EG, Avery R, Tomblyn M, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis. 2014;58:e44–100.
67.
Flowers CR, Seidenfeld J, Bow EJ, Karten C, Gleason C, Hawley DK, et al. Antimicrobial prophylaxis and outpatient management of fever and neutropenia in adults treated for malignancy: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol. 2013;31:794–810.CrossRefPubMed
68.
Tejero E, Mainar A, Fernández L, Tobío R, De Gregorio MA. New procedure for the treatment of colorectal neoplastic obstructions. Dis Colon Rectum. 1994;37:1158–9.CrossRefPubMed
69.
Carpenter CF, Gilpin N. Peritonitis, spontaneous bacterial and secondary. In: Pham PA, Auwaerter PG, Bartlett JG, Johns Hopkins M, editors. Johns Hopkins ABX guide: diagnosis and treatment of infectious diseases [e-book]. Burlington: Jones and Bartlett Learning; 2012. Available from: eBook Collection (EBSCOhost), Ipswich. Accessed 20 Sept 2015.
70.
Phitayakorn R, Delaney CP, Reynolds HL, Champagne BJ, Heriot AG, Neary P, et al. Standardized algorithms for management of anastomotic leaks and related abdominal and pelvic abscesses after colorectal surgery. World J Surg. 2008;32:1147–56.CrossRefPubMed
71.
Bovill E, Banwell PE, Teot L, Eriksson E, Song C, Mahoney J, et al. Topical negative pressure wound therapy: a review of its role and guidelines for its use in the management of acute wounds. Int Wound J. 2008;5:511–29.CrossRefPubMed
72.
Walters MD, Dombroski RA, Davidson SA, Mandel PC, Gibbs RS. Reclosure of disrupted abdominal incisions. Obstet Gynecol. 1990;76:597–602.PubMed
73.
Keepanasseril A, Suri V, Prasad GR, Gupta V, Bagga R, Aggarwal N, et al. Management of massive hemorrhage in patients with gestational trophoblastic neoplasia by angiographic embolization: a safer alternative. J Reprod Med. 2011;56:235–40.PubMed
74.
Biswal BM, Lal P, Rath GK, Mohanti BK. Hemostatic radiotherapy in carcinoma of the uterine cervix. Int J Gynaecol Obstet. 1995;50:281–5.CrossRefPubMed
75.
Geisler JP, Denman BJ, Cudahy TJ, Lee TH, Geisler HE. Ovarian carcinoma presenting as intra-abdominal hemorrhage. Gynecol Oncol. 1994;53:380–1.
76.
La Fianza A, Cassani C, Ori Belometti G. Intralesional hemorrhage in Krukenberg tumor: a case report and review of the literature. J Ultrasound. 2013;16:89–91.