Presurgical assessment of intraabdominal visceral fat in obese patients with early-stage endometrial cancer treated with laparoscopic approach: Relationships with early laparotomic conversions

Simple radiologic assessment of visceral obesity and prediction of surgical morbidity in endometrial cancer patients undergoing laparoscopic aortic lymphadenectomy: A reliability and accuracy study

AIM

To evaluate the reliability of sagittal abdominal diameter (SAD)-a surrogate of visceral obesity-in magnetic resonance imaging, and its accuracy to predict the surgical morbidity of aortic lymphadenectomy.

METHODS

We conducted a multicenter reliability (phase 1) and accuracy (phase 2) cohort study in three Spanish referral hospitals. We retrospectively analyzed data from the STELLA-2 randomized controlled trial that included high-risk endometrial cancer patients undergoing minimally invasive surgical staging. Patients were classified into subgroups: conventional versus robotic-assisted laparoscopy, and transperitoneal versus extraperitoneal technique. In the first phase, we measured the agreement of three SAD measurements (at the umbilicus, renal vein, and inferior mesenteric artery) and selected the most reliable one. In phase 2, we evaluated the diagnostic accuracy of SAD to predict surgical morbidity. Surgical morbidity was the main outcome measure, it was defined by a core outcome set including variables related to blood loss, operative time, surgical complications, and para-aortic lymphadenectomy difficulty.

RESULTS

In phase 1, all measurements showed good inter-rater and intra-rater agreement. Umbilical SAD (u-SAD) was the most reliable one. In phase 2, we included 136 patients. u-SAD had a good diagnostic accuracy to predict surgical morbidity in patients undergoing transperitoneal laparoscopic lymphadenectomy (0.73 in ROC curve). It performed better than body mass index and other anthropometric measurements. We calculated a cut-off point of 246 mm (sensitivity: 0.56, specificity: 0.80).

CONCLUSIONS

u-SAD is a simple, reliable, and potentially useful measurement to predict surgical morbidity in endometrial cancer patients undergoing minimally invasive surgical staging, especially when facing transperitoneal aortic lymphadenectomy.

Transperitoneal Laparoscopic Para-Aortic Lymphadenectomy and Body Mass Index: Is It Really a Limiting Factor for the Procedure?

Objective: To explore if obesity measured by body mass index (BMI) ≥30 kg/m² represents a limiting factor for para-aortic lymphadenectomy done with a transperitoneal laparoscopic approach. Materials and Methods: Retrospective observational study with 146 consecutive patients, diagnosed with a gynecological cancer submitted to para-aortic surgical staging between January 2010 and December 2018. The mean age was 52 years and the mean BMI was 27 kg/m². 72.6% (106 patients) had BMI <30 kg/m² and 27.4% (40 patients) had BMI ≥30 kg/m². Half of the patients did not have prior abdominal surgeries. Results: The statistical analysis showed that there were no significant differences between two groups depending on their BMI in the lymph node count: BMI <30 kg/m² 14 nodes versus BMI ≥30 kg/m² 10 nodes (P = .122); rate of intraoperative complications: BMI <30: 6.3% versus BMI ≥30: 0% (P = .180), postoperative complications: BMI <30: 6.6% versus BMI ≥30: 5% (P = .723); feasibility rate: BMI <30: 97.1% versus BMI ≥30: 95.6% (P = .063) or the mean hospital stay BMI <30: 2.47 ± 2.05 days (standard deviation [SD]), BMI ≥30: 2.64 ± 0.93 days (SD) (P = .171). The only significant difference observed was due to the operating time: BMI <30: 103.1 ± 60.8 (SD) versus BMI ≥30: 146.9 ± 82.5 (SD) (P = .019), being longer in obese patients. Conclusions: Obesity, estimated by BMI, does not seem to represent a limiting factor for this surgical procedure in our series. We feel it is a feasible and justified approach in obese patients when other surgical procedures have to be carried out in the same surgical act. Probably, other factors and anthropometric measurements are more accurate to select patients in which this approach is feasible.

Periaortic Abdominal Fat Area as a Predictor of Surgical Difficulties during Extraperitoneal Laparoscopic Para-aortic Lymphadenectomy

STUDY OBJECTIVE

To evaluate whether obesity is a marker of surgical difficulty during extraperitoneal para-aortic lymphadenectomy.

DESIGN

Retrospective observational cohort study.

SETTING

Tertiary medical center in the Kanazawa area of Japan.

PATIENTS

Eighty-four patients with primary endometrial cancer who underwent extraperitoneal laparoscopic para-aortic lymphadenectomy (LPAND) between January 2005 and December 2017 were included.

INTERVENTIONS

We investigated the correlation between operative times and body mass indexes, visceral fat areas, and periabdominal artery fat areas (PAFAs). The number of lymph nodes harvested was used as an indicator of the degree of surgical completion.

MEASUREMENTS AND MAIN RESULTS

There was no correlation between the operative time and body mass index. Significant correlations were observed between operative time and visceral fat area (p = .026; r = 0.243) and between operative time and PAFA (p = .007; r = 0.293). A multivariate analysis showed that PAFA was a significant independent marker that could be used to predict prolonged operative times for extraperitoneal LPAND (p = .045; odds ratio, 3.05). The number of para-aortic lymph nodes harvested was not significant in the high- and low-PAFA groups (22 and 25, respectively; p = .525).

CONCLUSION

PAFA is an adequate marker of prolonged operative time for extraperitoneal LPAND among patients with endometrial cancer.

Laparoscopic and robotic hysterectomy in endometrial cancer patients with obesity: a systematic review and meta-analysis of conversions and complications

OBJECTIVE DATA

Robotic assistance may facilitate completion of minimally invasive hysterectomy, which is the standard of care for the treatment of early-stage endometrial cancer, in patients for whom conventional laparoscopy is challenging. The aim of this systematic review was to assess conversion to laparotomy and perioperative complications after laparoscopic and robotic hysterectomy in patients with endometrial cancer and obesity (body mass index, ≥30 kg/m²).

STUDY

We systematically searched MEDLINE, EMBASE, and Evidence-Based Medicine Reviews (January 1, 2000, to July 18, 2018) for studies of patients with endometrial cancer and obesity (body mass index, ≥30 kg/m²) who underwent primary hysterectomy.

STUDY APPRAISAL AND SYNTHESIS METHODS

We determined the pooled proportions of conversion, organ/vessel injury, venous thromboembolism, and blood transfusion. We assessed risk of bias with the Institute of Health Economics Quality Appraisal Checklist for single-arm studies, and Newcastle-Ottawa Quality Scale for double-arm studies.

RESULTS

We identified 51 observational studies that reported on 10,800 patients with endometrial cancer and obesity (study-level body mass index, 31.0-56.3 kg/m²). The pooled proportions of conversion from laparoscopic and robotic hysterectomy were 6.5% (95% confidence interval, 4.3-9.9) and 5.5% (95% confidence interval, 3.3-9.1), respectively, among patients with a body mass index of ≥30 kg/m², and 7.0% (95% confidence interval, 3.2-14.5) and 3.8% (95% confidence interval, 1.4-9.9) among patients with body mass index of ≥40 kg/m². Inadequate exposure because of adhesions/visceral adiposity was the most common reason for conversion for both laparoscopic (32%) and robotic hysterectomy (61%); however, intolerance of the Trendelenburg position caused 31% of laparoscopic conversions and 6% of robotic hysterectomy conversions. The pooled proportions of organ/vessel injury (laparoscopic, 3.5% [95% confidence interval, 2.2-5.5]; robotic hysterectomy, 1.2% [95% confidence interval, 0.4-3.4]), venous thromboembolism (laparoscopic, 0.5% [95% confidence interval, 0.2-1.2]; robotic hysterectomy, 0.5% [95% confidence interval, 0.1-2.0]), and blood transfusion (laparoscopic, 2.8% [95% confidence interval, 1.5-5.1]; robotic hysterectomy, 2.1% [95% confidence interval, 1.6-3.8]) were low and not appreciably different between arms.

CONCLUSION

Robotic and laparoscopic hysterectomy have similar rates perioperative complications in patients with endometrial cancer and obesity, but robotic hysterectomy may reduce conversions because of positional intolerance in patients with morbid obesity. Existing literature is limited by selection and confounding bias, and randomized trials are needed to inform practice standards in this population.

Using simple radiologic measurements to anticipate surgical challenge in endometrial cancer: a prospective study

Objectives

To determine if linear measurements of adiposity from pre-operative imaging can improve anticipation of surgical difficulty among endometrial cancer patients.

Methods

Eighty patients with newly diagnosed endometrial cancer were enrolled. Routine pre-operative imaging (MRI or CT) was performed. Radiologic linear measurements of the following were obtained: anterior-to-posterior skin distance; anterior skin to anterior edge of L5 distance (total anterior); anterior peritoneum to anterior edge of L5 distance (visceral obesity); and posterior edge of L5 to posterior skin distance (total posterior). Surgeons completed questionnaires quantifying preoperative anticipated operative difficulty and postoperative reported operative difficulty. The primary objective was to assess for a correlation between linear measurements of visceral fat and reported operative difficulty.

Results

Seventy-nine patients had questionnaires completed, preoperative imaging obtained, and surgery performed. Univariate analysis showed all four linear measurements, body mass index, weight, and anticipated operative difficulty were associated with increased reported operative difficulty (P< 0.05). Multivariate analysis demonstrated that body mass index and linear measurements visceral obesity and total posterior were independently associated with increased reported operative difficulty (P< 0.05). Compared with body mass index, the visceral obesity measurement was more sensitive and specific for predicting increased reported operative difficulty (visceral obesity; sensitivity 54%, specificity 91 %; body mass index; sensitivity 38%, specificity 89%). A difficulty risk model combining body mass index, visceral obesity, and total posterior demonstrated better predictive performance than any individual preoperative variable.

Conclusions

Simple linear measurements of visceral fat obtained from preoperative imaging are more predictive than body mass index alone in anticipating surgeon-reported operative difficulty. These easily obtained measurements may assist in preoperative decision making in this challenging patient population.

Left Lateral Endosurgical Extraperitoneal Total Hysterectomy with Para-Aortic and Pelvic Lymphadenectomy: A Novel Approach for the Obese Patient with Endometrial Cancer

STUDY OBJECTIVE

To describe the left lateral extraperitoneal approach to perform complete para-aortic and pelvic lymphadenectomy and transverse total hysterectomy from left to right as a novel approach to treat obese patients with endometrial cancer. Laparoscopic management of obese patients represents a challenge for the gynecologic surgeon. The extraperitoneal approach is technically easier in the obese patient because it naturally creates a bowel-free operative field.

DESIGN

A prospective pilot bicentric and descriptive study (Canadian Task Force classification III) evaluating the feasibility and reproducibility of the transverse total hysterectomy and complete lymphadenectomy through left endoscopic extraperitoneal approach in obese patients with endometrial cancer.

SETTING

A comprehensive cancer center in Toulouse and a teaching university hospital in Madrid.

PATIENTS

Sixteen consecutive overweight or obese patients (body mass index > 25 kg/m²) with high-risk endometrial cancer.

INTERVENTIONS

Currently, the left extraperitoneal approach is routinely used to perform complete para-aortic and pelvic lymphadenectomy. It provides direct access to the left ureter and uterine pedicle. This access can be extended to the right side when performing a transverse extrafascial hysterectomy from left to right. The procedure starts from the left extraperitoneal space, where the left uterine artery is sectioned and the vesicovaginal and rectovaginal septa are developed, without opening the peritoneum. Colpotomy is performed from the left to the right side. Once the right ureter is identified, the right uterine artery can be safely transected. Alternatively, the right uterine artery can be sealed and sectioned during the right pelvic lymphadenectomy. At the end of the procedure the peritoneum is opened to complete the surgery.

MEASUREMENTS AND MAIN RESULTS

Between May 2015 and February 2016, 16 consecutive obese patients were successfully treated using this technique. Median patient age was 62 years (range, 44-78), and median body mass index was 32.5 kg/m² (range, 26-42). In 3 cases the right uterine artery was sealed during the right pelvic lymphadenectomy, in 11 cases after completing vaginal opening, and in 2 cases after peritoneal opening. The median operative time was 137.5 minutes (range, 66-260). The median blood loss was 85 mL (range, 0-260), and no blood transfusion was required in any of our 16 patients. No significant complications occurred.

CONCLUSION

The full extraperitoneal approach represents an interesting alternative strategy for the surgical treatment of obese patients with high-risk endometrial cancer.

Predictive Factor of Conversion to Laparotomy in Minimally Invasive Surgical Staging for Endometrial Cancer

OBJECTIVE

The aim of the study was to identify risk factors associated with laparotomy conversion during total laparoscopic hysterectomy for endometrial cancer.

METHODS

This is a retrospective study examining endometrial cancer cases that underwent hysterectomy-based surgical staging initiated via conventional laparoscopic approach. Factors related to patient, tumor, and surgeon were examined to establish risk of laparotomy conversion using a multivariate logistic regression model.

RESULTS

There were 251 cases identified including 30 cases (12.0%) of laparotomy conversion. The most common indication for laparotomy conversion was a large uterus (27.0%), followed by extensive adhesions (24.3%) and surgical complications (18.9%). Outcomes of cases resulting in laparotomy conversion include longer surgical time (333 vs 224 minutes, P < 0.001), larger blood loss (350 vs 100 mL, P < 0.001), longer hospital stay (4 vs 2 days, P < 0.001), and increased risk of hospital readmission (10% vs 1.4%, P = 0.024). In multivariate analysis, morbid obesity (odds ratio [OR], 4.51; P = 0.011), suboptimal pelvic examination or enlarged uterus during preoperative evaluation (OR, 3.55; P = 0.034), para-aortic lymphadenectomy (OR, 10.5; P = 0.001), uterine size 250 g or greater (OR, 3.49; P = 0.026), and extrauterine disease (OR, 4.68; P = 0.012) remained the independent predictors for laparotomy conversion. The following numbers of risk factors were significantly correlated with laparotomy-conversion rate: none, 1.1%; single risk factor, 5.3% (OR, 5.00; P = 0.15); double risk factors, 21.7% (OR, 24.9; P = 0.002); and triple or more risk factors, 50% (OR, 90.0; P < 0.001). Ultrasonographic 3-dimensional volumes of 496 cm in preoperative uterine size correlate with actual uterine weight of 250 g (Y = 61.5 + 0.38X, P < 0.001).

CONCLUSIONS

Laparotomy conversion significantly impacts outcomes of patients with endometrial cancer. In this setting, our predictive model for laparotomy conversion will be useful to guide the surgical management of endometrial cancer.

Computed Tomography Morphometrics and Pulmonary Intolerance in Endometrial Cancer Robotic Surgery

STUDY OBJECTIVES

To identify morphometric characteristics of obese patients that best predict pulmonary intolerance to robotic pelvic surgery using a novel method for quantifying adipose distribution.

DESIGN

Retrospective study (Canadian Task Force classification II-2).

SETTING

University hospital.

PATIENTS

Fifty-nine patients with endometrial cancer who underwent robotic hysterectomy and lymphadenectomy between April 2008 and May 2014 and also underwent perioperative computed tomography (CT) imaging within 1 year.

INTERVENTION

Visceral fat volume (VFV) and subcutaneous fat volume (SFV) were quantified through waist circumference measurements along with average volume estimation of slices taken at 3 levels: mid-waist, L2-L3, and L4-L5. Mean and maximum values were obtained for intraoperative physiological data.

MEASUREMENTS AND MAIN RESULTS

The patients' mean body mass index (BMI) was 34 (range, 20-59). Along with waist circumference, VFV and SFV quantified by CT at the mid-waist, L2-L3, and L4-L5 levels were all significant independent predictors for peak airway pressure (PAP; average and maximum) and plateau airway pressure (Pplat; average and maximum) on multivariate regression analysis after adjustment for age, ethnicity, diabetes, hypertension, pulmonary disease, smoking, obstructive sleep apnea, American Society of Anesthesiologists classification, and duration of anesthesia. Compared with the other CT parameters, L2-L3 VFV was the best predictor of average PAP (β = 0.398; p = .002), maximum PAP (β = 0.493; p < .001), average Pplat (β = 0.536; p < .001), and maximum Pplat (β = 0.573; p < .001).

CONCLUSION

These novel CT morphometric measurements represent valid predictors of pulmonary intolerance to robotic surgery in obese patients. Of the measures analyzed, VFV at L2-L3 best predicts pulmonary tolerance in obese patients.

Magnetic resonance or computerized tomography imaging to predict difficulty of robotic surgery for endometrial cancer

To determine if the difficulty of a robotic hysterectomy for endometrial cancer can be predicted by MRI, CT or other methods. All robotic cases from 1 August 2006 through 30 July 2009 were identified. Data collected prospectively included co-morbidities, body mass index, surgical times, estimated blood loss (EBL), uterine weight, and pre- and postoperative complications. Those patients who received an MRI or CT scan prior to robotic hysterectomy had additional data gathered from imaging, including uterine volume, pelvic measurements and abdominal wall thickness. Cases were labeled difficult for the following reasons: outliers greater than 2 SD from the mean EBL, hysterectomy time and total console time. Additional factors identifying difficult cases included the need to undock to remove the specimen or conversion to laparotomy. Data were analyzed for their possible role in causing difficulty in a robotic hysterectomy. Comparative statistics utilized included chi-square and t-test, ANOVA and logistic regression analysis.From 2 August 2006 through 30 July 2009, 119 patients underwent robotic surgery for endometrial cancer and are included in this study. Of these patients, 25/119 (20.0%) were identified as difficult cases. Difficulty was found in those patients with greater than 2 SD from the mean for hysterectomy time, >90.9 min (n = 3, 2.5%), total console time of >178.1 min (n = 6, 5.0%), EBL >232 cc (n = 7, 5.9%) and undocking to remove the uterine specimen in 8 (6.7%) cases; 1/119 (0.8%) was converted to laparotomy. Lymphadenectomy (P = 0.005) was associated with case difficulty. In a logistic regression analysis CT/MRI measurements of uterine volume greater than 793 cm³ and CT/MRI pelvimetry, as well as abdominal wall thickness were independent predictors of a difficult case (P = 0.0116). MRI and CT scans can detect the probability that a robotic surgery will be difficult by determining uterine volume and pelvimetry; however, these were not the strongest predictors in our study. A narrow pelvic outlet as measured on CT/MRI and uterine volume of greater than 793 cc should raise a flag of caution when planning robotic hysterectomy for endometrial cancer.

[Are there still contra-indications to laparoscopic treatment of endometrial carcinoma?]

Laparoscopic treatment is becoming a standard of care for early endometrial carcinoma. However, not all patients are suitable for this approach. A review of the current literature provides some arguments to differentiate absolute contra-indications from relative ones, for which, whenever possible, some options are suggested.