late effects from surgerylate effects from surgery j. sehouli director of the department of...

LATE EFFECTS

from Surgery

J. Sehouli

Director of the Department of GynecologyEuropean Competence Center for Ovarian

CancerCharité Comprehensive Cancer Center

Charité/ Campus Virchow-Klinikum

University of Berlin

©Sehouli 2017 Charité Berlin

http://www.charite.de/de/

V. renalis sinistra

V. cava sinistra

V. cava

dextra

A. renalis dextra

A. mestenterica inf.

V. renalis dextra

A. Iliaca dextra

A. Iliaca sin

V. ovarica sinistraUreter sin.

Plexus

hypogastricus

Aorta abdominalis

V. ovarica dextra

N. Ilio-inguinalis sin©Sehouli 2017 Charité Berlin

Modifications➢ Preperation of ureter

➢ Resection of

Lig. sacro-uterinum

➢ Resection of parametry

➢ Vaginal cuff

➢ Adnectomy

➢ Nerve sparing

techniques

➢ En bloc resections

(across compartment

surgery)


http://www.charite.de/de/

Charité2017Muallem©

„Surgery will never cause late

toxities, it is only caused by

adjuvant therapy!“


https://www.google.de/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwic-LT6m53XAhVJSRoKHQeyDHQQjRwIBw&url=https%3A%2F%2Fwww.vallartadaily.com%2Fcolumnists%2Fopinions%2Ffake-news%2F&psig=AOvVaw28FVqzG2B6KLJfEg7v_Yt-&ust=1509620274942543

intraoperative

Anesthesia

aspiration

Cardiac arrest

trachea injury

pneumothorax

positioning injury

surgical:

„Operability“

Rogan injuries

bleeding (tumorinduced/iatrogen)

nerve leasions(positioning)

postoperative

Internistisch:

Thromboembol.

cardiopulmonary morbidity

Infections

SIRS

Liver failure

TakotsuboCardiomypathy

surgical:

Fistula/ Perforations, (bowel, pancreas, bladder, stomach,

vessels)

secondary woundhealing

peritonitis

hemorraghy

Bowel obstruction

Ischemia/Infarct

lymphorroe

compartmentsyndr.

emboly

COMPLICATIONS

MORBIDITY - MORTALITY©Sehouli 2017 Charité Berlin

Surgery and late toxicities

➢Methodical limitations

➢Most of the reports retrospective and

monocentric

➢Underreporting of side effects

➢Unsystematic application of toxicity

scales (eg. Clavien-Dindo):

➢Questionaire: Who? When? How?


https://www.google.de/imgres?imgurl=https%3A%2F%2Fcdn.pixabay.com%2Fphoto%2F2015%2F10%2F30%2F09%2F44%2Fcaught-1013600_960_720.jpg&imgrefurl=https%3A%2F%2Fpixabay.com%2Fen%2Fcaught-prison-chain-metal-figure-1013600%2F&docid=efUl3KvylKdifM&tbnid=c-xgfAdgVodDdM%3A&vet=1&w=720&h=720&bih=484&biw=1067&ved=0ahUKEwjro5qloZ3XAhVCwxQKHT3UDOoQxiAIGigC&iact=c&ictx=1

Surgery and late toxicities

➢Frequent use of adjuvant (multimodal

therapies)

➢Influence of comorbidities and

comedication are generally ingnored

➢Long term toxicities need long term

observation and awareness!


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...“drains to prevent

lymphocyst formation

can safely be omitted

following radical

hysterectomy and

pelvic LND“


Epidemiology about lymph edema in gynecologicalcancer patients

• Only few prospective multicentric data• Most only short observation time

• High bias of adjuvant therapies and comorbidities

Quality of life

Forgynecologicalmalignanciesincidence of

40%

Adipositas and cardio-vasculary

diseases havesignificantimpact on incidence

Füller J et al.Lymph Edema of the Lower Extremities after Lymphadenectomy and Radiotherapy for Cervical Cancer 2008

Ohba Y et al. Risk factors for lower-limb lymphedema after surgery for cervical cancer Int J Clin Oncol. 2011

Neuhüttler S. et al. Beitrag zur Epidemiologie des Lymphödems. Phlebologie 2003

Ryan M. et al. Aetiology and prevalence of lower limb lymphoedema following treatment for gynaecological cancer. Aust N Z J Obstet

Gynaecol 2003

Greene AK et al. Obesity induced lymphedema: clinical and lymphoscintigraphic features. Plast Reconstr Surg 2015

Dale RF. Et al. The inheritance of primary lymphoedema. Journal of Medical Genetics 1985

Foldi M. et al. Das vernachlässigte Gefäßsystem. MMW-FortschritMed 2004 ©Sehouli 2017 Charité Berlin

Patients with arm

lymphedama:diagnosis of secondary arm lymphedema

in 86% of the patients within 12 months

(0.6 +/- 2.3 years)

Patients with leg

lymphedemaaverage time to diagnosis 0.5 +/- 1.8 years

(1.7 +/- 3.8 years)

Blome et al. Lymphedema – the long way to diagnosis

and therapy VASA 2013©Sehouli 2017 Charité Berlin

https://www.google.de/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiSqpWIsJ3XAhUSrRQKHQ0uBzEQjRwIBw&url=https%3A%2F%2Fwww.123rf.com%2Fphoto_12221937_grunge-facts-stamp.html&psig=AOvVaw3Homdww5Xn4ZcwEsxwGyM9&ust=1509625682309316

Psychological stress

34% increased psycholgical stress (35% needsprofessional support)

Quality of life andbody imaging conceptare inferior

Cancer patients with

lymphedema have a signifikant

higher risk for depression and

psychological dysbalances

VitalityPsychostatus

Performance Status

Williams AF. et al. A phenomenological study of the lived

experiences

of people with lymphoedema. Int J Palliat Nurs 2004

McWayne J. et al. Psychologic and social sequelae of secondary

lymphedema: a review. Cancer 2005

QoL


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LEL + LEL -

LND Pelvic

and

paraortal

LND

pelvic

40 62.5%

24 37.5%

37 57.8%

27 42.2%

Lymphedema in gynecological cavcer patients…the Charité experience and the experience of

others… (results of a prospective study*)

N

45

54 LEL + group has

with 46.3% > 30 N

LEL – group has with

20% > 30 N

Odds Ratio: 3,4

p-Wert = 0,006

©Sehouli 2017 Charité Berlin *not yet published:Auletta,Sehouli,Vercellino

*Effect of radiochemotherapy on lymphedema

LEL +LEL + group has received in

38.9% adjuvant

radiochemotherapy

LEL –LEL + group

received in 15% adjuvant

radiochemotherapy

33

21

9

51

none

Radiochemo

therapy

no

Radiochemo

therapy

Odds Ratio 3,6

p-Wert = 0,004 ©Sehouli 2017 Charité Berlin*not yet published:Auletta,Sehouli,Vercellino

N=251 Cervical cancer

(2005-2013)

…the Charité experience and the experience

of others… (results of a prospective study*)

©Sehouli 2017 Charité Berlin*not yet published:Windemuth,Sehouli,Baessler

Bladder Score

…the Charité experience and the experience

of others… (results of a prospective study*)


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Pressing at the stool*


Feeling of missing stool evacuation*


Bowel dysfunction after surgery*

+/-

+/- +/- +/-+/-

- - --

+ -


Sexual function score*

+/- +/- +/-+/-

- - --

+/- + -


Pelvic floor dysfunction*


https://www.google.de/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjX_e77zJ3XAhWExxQKHbDSC6QQjRwIBw&url=https%3A%2F%2Fpelvicguru.com%2F2013%2F01%2F12%2Fthe-ultimate-pelvic-anatomy-resource-articles-links-and-videos-oh-my%2F&psig=AOvVaw0lrlp7VKsmOr0080OwYTMu&ust=1509633383565707

➢Use of information resources about sexuality after gynecological cancer

therapies

No information 40%

physician(s) 25%

brochures 15%

relatives 5%

friends 5%

other patients 5%

partner 5%

internet 5%

Pilger A, Richter R, Fotopoulou C, Beteta C, Klapp C, Sehouli J.

Anticancer 2012©Sehouli 2017 Charité Berlin

Quality of life and sexuality of patients after treatment for

gynaecological malignancies: results of a prospective study in

55 patients.

Pilger A, Richter R, Fotopoulou C, Beteta C, Klapp C, Sehouli J.

Anticancer Res. 2012 Nov;32(11):5045-9.

78% of the patients suffered from sexual

dysfunction

Reasons:

➢ feeling of losting her atractivity 45%

➢ Dryness of the vagina 25%

➢ Dyspareunia 20%

Similar results: Hopkins et al. Climacteric 2014©Sehouli 2017 Charité Berlin

https://www.ncbi.nlm.nih.gov/pubmed/23155277

Quality of life after surgery and

chemotherapy in ovarian cancer

Richter R, Oskay-Oezcelik G, Chekerov R, Pilger A, Hindenburg HJ, Sommer H, Camara O, Keil E,

Einenkel J, Sehouli J, Anticancer 2012.

Longterm side effects in gynecological

cancer patients

➢ n=1029 pts

(median 4.9 years)

Westin et al. J Cancer Surviv

2016

Cancer as a chronic disease

➢ Worldwide, every year more than 14 millions will be

primary diagnosed wit cancer

➢ More than 65% of the cancer patients will survive

more than 5 years

➢ Tendency of significant increasements for both facts

WHO 2016


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Expression VI

http://carolinmeetshanna.com/


➢ Critical indication for any surgical procedures for

every individual patient

➢ Best surgical techniques with preserving healt

thissues and compartments (incl. Nervesparing

aproach)

➢ Be critical for adjuvant therapies (what therapy

for what goal)

➢ Systematic evaluation of acute and late toxicities

➢ Create a systematic interprifessional and

interdisciplinary network for best supportive care

➢ Conduction of prospective trials focussing on

lymphedema, bladder and stoll function,

sexuality and QoL


late effects from surgerylate effects from surgery j. sehouli director of the department of...

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