Objective Women with recurrent gynaecological cancers who are not suitable for exenterative surgery commonly present with gastrointestinal dysfunction. This paper is a retrospective review of the use of gastrostomy tubes in such women. MethodsWe performed a chart review of women with recurrent gynaecological cancer who had a gastrostomy tube placed between January 1991 and April 1998.Results Thirty-nine women (mean age 53.2 years, range 17-82) had a gastrostomy tube placed. liventyeight (72%) had ovarian cancer, eight (21%) had cervical cancer, two had endometrial cancer and one had vaginal cancer. In 14 women a gastrostomy tube was placed as the sole procedure for palliation (1 1 elective, 3 emergency). In the remaining 25 women, who underwent major surgery, a gastrostomy tube was placed in anticipation of, or in the presence of, significant intestinal distension and expected prolonged post-operative ileus. Eleven women (28%) died without leaving hospital after their operation (median 11 days, range 2-36). All but one of the 28 women who left hospital had satisfactory oral intake. Twenty-one women (54%) died with the gastrostomy tube in place (median 28 days, range 2-157) and 18 (46%) had the gastrostomy tube removed (median 14.5 days, range 9-180), 13 of whom (33%) have since died (median 167 days, range 77 days-7 years). Five women (13%) are alive (median 2.2 years, range 10 months45 years). There were no problems which required the gastrostomy tube to be removed. ConclusionGastrostomy tubes have an important role in the treatment of women with recurrent gynaecological cancer, allowing gastric drainage and decompression without the disadvantages of nasogastric tubes.

We report a technique for safe laparoscopic access for gynaecological surgery in women who have had their abdominal wall reconstructed by plastic surgery. The abdominal wall incisions for placement of the trocars are made in the abdominoplasty scars and are cosmetically acceptable. In a limited series there appears to be no excess morbidity.In our cancer centre, we are seeing more women who have been advised to have ovarian ablation for adjuvant treatment of their breast cancer. An increasing number of these women have undergone primary reconstruction of the breast when having their definitive surgical treatment of the cancer. The transverse rectus abdominis myocutaneous flap is considered the 'gold standard' for breast reconstruction. This, allied with the escalating incidence of breast cancer 2 and a preferred use for surgical ovarian ablation for hormonal manipulation especially in ER-positive breast cancers, presented us with the need to manage women who had abdominal plastic surgery. Abdominoplasty and reconstructive surgery to the abdominal wall are considered contraindications to laparoscopic surgery, as the usual landmarks for entry are altered and there is significant scarring. A report suggested that the laparoscopic approach was possible, 3 although this either used an approach through the relocated umbilicus or used Palmer's point in the left upper quadrant.Following the use of the rectus abdominis as part of the breast reconstruction, the anterior abdominal wall is scarred by the abdominoplasty scar. The neo-umbilicus is relocated away from the original congenital cicatrix at the condensation of the rectus aponeurosis to a more cosmetically correct position and is often refashioned. Thus, it is not necessarily helpful either as a landmark or as an easy portal for entry as in normal laparoscopy. In addition, a nonabsorbable mesh has often been inserted to prevent hernia formation. The significant scarring, the mesh and the relocation of the umbilicus (an important landmark for most laparoscopy) are the contraindications for laparoscopic surgery. We felt that the use of the left upper quadrant entry (Palmer's point) may jeopardise the vascular pedicle for the transverse rectus abdominis myocutaneous flap used for the right breast reconstruction (left superior epigastric pedicle). We have therefore developed the described technique. The women were warned of the risks of laparoscopic surgery given the above concerns about scarring. All women gave informed consent for the procedure including the novel technique. TechniqueWomen who have been advised by the multidisciplinary breast team to have oophorectomy as part of their treatment are referred to our unit for discussion and surgery. In addition, there are women referred who have had plastic surgery and have coincidental gynaecological pathology. The procedure is described including possible complications and informed consent obtained. Under general anaesthetic, the woman is placed supine on the operating table and catheterised. A subcutaneous injection ...

We studied the safety of early postoperative enteral feeding in 22 patients with recurrent gynaecological cancer who underwent major abdominal surgery including extensive adhesiolysis, bowel resection and bowel anastomosis. A total of 19 patients (86.4%) had been treated by both radical surgery and radiation therapy with curative intent. In 18 cases (81.8%), the indication for surgery was bowel obstruction. Preoperative total parenteral nutrition (TPN) was not used. Enteral feeding was given through a gastrostomy tube or a jejunal feeding tube and was commenced within 72 h of completion of surgery. The age range was 30-78 years with a median of 52.8 years. A total of 13 patients (59.1%) had a bowel resection and 17 patients (77.3%) had a bowel anastomosis, all stapled. The median maximum tolerated full strength feeding was 50 ml/h for 18-20 h in a 24 h period and maintained for a median of 9 days. In six patients the feeding was interrupted but was re-commenced in five, in four of whom there was no further interruption of feeding. There were no anastomotic leaks and no cases of aspiration. Postoperative enteral feeding was safe in patients with recurrent gynaecological cancer who had undergone major abdominal surgery and should be considered as an alternative to TPN.

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