title: Surgical technique of diaphragm full-thickness resection and trans-diaphragmatic decompression of pneumothorax during cytoreductive surgery for ovarian cancer.
abstract: OBJECTIVE
  To describe the technique and short-term post-operative outcomes associated with diaphragm full-thickness resection (FTR) and intraoperative trans-diaphragmatic decompression of the resultant pneumothorax (TDDP).
  
  
  METHODS
  All patients undergoing cytoreductive surgery for primary or recurrent ovarian cancer between 8/1/98 and 7/30/09 were retrospectively identified from the tumor registry database. Patients undergoing diaphragm FTR were selected for detailed review of the operative technique and post-operative outcomes. The operative technique of TDDP using a fenestrated Robinson catheter is described.
  
  
  RESULTS
  A total of 45 patients met study inclusion criteria. Diaphragm FTR surgery was performed exclusively by gynecologic oncologists in 73.3% of cases. The median patient age was 60 years, and the majority (75.6%) of cases were performed for primary cytoreduction of Stage IIIC (n=27) or Stage IV (n=18) disease. The two-dimensional surface area of tumor involvement ranged from 9 cm(2) to 192 cm(2). The right hemi-diaphragm alone was involved in 71.1% of cases, while both the right and left hemi-diaphragms were involved in 24.4%. TDDP was performed in 41 of the 45 patients undergoing diaphragm FTR, while 4 patients had intraoperative thoracostomy tubes placed. Among the 41 TDDP patients, post-operative days 3-4 radiographic imaging revealed that 56% had a small residual pleural effusion and 9.8% had a residual pneumothorax; however, only 2 patients (4.9%) required post-operative thoracostomy tube placement or thoracentesis.
  
  
  CONCLUSIONS
  The technique of TDDP eliminates the need of intraoperative and post-operative thoracostomy tube/thoracentesis in 95.1% of patients undergoing diaphragm FTR as a component of ovarian cancer cytoreductive surgery.
authors.affiliation: The Kelly Gynecology and Oncology Service, Department of Gynecology and Obstetrics, The Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins Medical Institutions, Baltimore, MD 21287, USA. sbashir4@jhmi.edu
authors.forename: Shazia
authors.initials: S
authors.lastname: Bashir
authors.forename: Melissa A
authors.initials: MA
authors.lastname: Gerardi
authors.forename: Robert L
authors.initials: RL
authors.lastname: Giuntoli
authors.forename: Teresa P Diaz
authors.initials: TP
authors.lastname: Montes
authors.forename: Robert E
authors.initials: RE
authors.lastname: Bristow
mesh_terms: D000328:Adult; D000368:Aged; D019299:Decompression, Surgical / Q000009:adverse effects / Q000379:methods; D003964:Diaphragm / Q000601:surgery; D005185:Fallopian Tube Neoplasms / Q000473:pathology / Q000601:surgery; D005260:Female; D013509:Gynecologic Surgical Procedures / Q000009:adverse effects / Q000379:methods; D006801:Humans; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000473:pathology / Q000601:surgery; D010051:Ovarian Neoplasms / Q000473:pathology / Q000601:surgery*; D010534:Peritoneal Neoplasms / Q000473:pathology / Q000601:surgery; D016066:Pleural Effusion, Malignant / Q000473:pathology; D011030:Pneumothorax / Q000209:etiology / Q000601:surgery*; D012189:Retrospective Studies; D016896:Treatment Outcome