Morcellation, To be or not to be?

October 1, 2015, no responses, by: Women Health Center, Tags:

In October 2013, Amy Reed, MD, PhD, underwent a hysterectomy procedure involving morcellation at Brigham & Women’s Hospital in Boston for what was presumed to be benign fibroids. All went fine until about 1 week later, when Dr. Reed, an anesthesiologist at Beth Israel Deaconess Hospital in Boston, received a phone call informing her that she had actually had a leiomyosarcoma, and that the procedure may have upstaged it to stage IV cancer.

Dr. Reed and her husband, Hooman Noorchashm, MD, PhD, a lecturer on surgery at Harvard Medical School and a cardiothoracic surgeon at Brigham and Women’s Hospital, are now on a mission to ban the practice of morcellation in any form. Their change.org petition received 1000’s of signatures.

In response to this both the The Royal Australasian College of Obstetricians and Gynaecologists  and the ACOG have now come out with a consensus statement regarding the use of morcellation. You can read more about morcellation here.

In Summary,

Gynaecologists should recognise that tissue extraction by morcellation may be associated with a number of risks:

1. Patient injury: other tissue, such as bowel, may be inadvertently injured during the morcellation process. The efficiency of electromechanical morcellation poses a specific hazard in this setting.

2. Dissemination: fragments of tissue generated by the morcellation process may disseminate throughout the peritoneal cavity. This has been reported for both benign disease (fibroids, endometriosis) and malignancy where this may have a detrimental effect on prognosis and / or increase the need for adjuvant treatment. Concerns have been expressed that electromechanical morcellators may increase the risk of dissemination by creating a larger volume of smaller fragments.

3. Pathology: the size of the fragments and, at times, the loss of anatomical relationships, may complicate the diagnosis by the pathologist. Concerns have been expressed that electromechanical morcellation may yield a large volume of small and dissociated fragments, which may further complicate analysis.

They suggest some guidelines to be followed to take into consideration the following.

1)      Case selection

2)      Preoperative assessment (specifically to assess the risk of malignancy, including a pap smear, ultrasound, tumour markets, endometrial sampling and/or extended imaging eg MRI’s etc.

3)      Consent

4)      Intraoperative assessment (be prepared to change your mind if anything suspicious is encountered).

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