{"paper_id":"d4c199ac-f8b1-40b6-b1fa-9ecd36bc1ba7","body_text":"Zhang et al. BMC Women’s Health          (2024) 24:274  \nhttps://doi.org/10.1186/s12905-024-03117-9\nCASE REPORT\nPerioperative management of a patient \nwith unexpectedly detected early-stage \novarian mucinous carcinoma combined \nwith progressive bulbar paralysis: a case report \nand literature review\nDingbei Zhang1†, Ruibo Xu2†, Tingting Huo3, Ying Liu4, Zengfang Hao5, Yao Sun1, Xiaoyu Xi1, Xiaoli Du6, \nLili Wang1 and Jiexian Du1* \nAbstract \nBackground Giant ovarian cysts (GOCs)complicated with progressive bulbar paralysis (PBP) are very rare, \nand no such literature about these cases have been reported. Through the diagnosis and treatment of this case, \nthe perioperative related treatment of such patients was analyzed in detail, and early-stage ovarian mucinous carci-\nnoma was unexpectedly found during the treatment, which provided reference for clinical diagnosis and treatment \nof this kind of diseases.\nCase presentation In this article, we reported a 38-year-old female patient. The patient was diagnosed with PBP \n2 years ago. Examination revealed a large fluid-dominated cystic solid mass in the pelvis measuring approximately \n28.6×14.2×8.0 cm. Carbohydrate antigen19-9(CA19-9) 29.20 IU/mL and no other significant abnormalities were \nobserved. The patient eventually underwent transabdominal right adnexal resection under regional anesthesia, \nepidural block. Postoperative pathology showed mucinous carcinoma in some areas of the right ovary. The patient \nwas staged as stage IA, and surveillance was chosen. With postoperative follow-up 1 month later, her CA19-9 \ndecreased to 14.50 IU/ml.\nConclusions GOCs combined with PBP patients require a multi-disciplinary treatment. Preoperative evaluation \nof the patient’s PBP progression, selection of the surgical approach in relation to the patient’s fertility requirements, \nthe nature of the ovarian cyst and systemic condition are required. Early mucinous ovarian cancer accidentally discov-\nered after operation and needs individualized treatment according to the guidelines and the patient’s situation. The \npatient’s dysphagia and respiratory function should be closely monitored during the perioperative period. In addition, \nmoral support from the family is also very important.\nOpen Access\n© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which \npermits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the \noriginal author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or \nother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line \nto the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory \nregulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this \nlicence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecom-\nmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.\nBMC Women’s Health\n†Dingbei Zhang and Ruibo Xu these authors contributed equally to this work \nand should be considered co-first authors.\n*Correspondence:\nJiexian Du\ndujiexian2009@sina.com\nFull list of author information is available at the end of the article\n\nPage 2 of 6Zhang et al. BMC Women’s Health          (2024) 24:274 \nBackground\nOvarian cysts are the most common female pelvic \nmasses, and when ovarian cysts are larger than 10 cm \nin diameter, they are called giant ovarian cysts (GOCs) \n[1]. GOCs can cause abdominal distention, pain, nau -\nsea and vomiting, and even intestinal obstruction and \nhydronephrosis.\nAmyotrophic lateral sclerosis (ALS) is a rapidly pro -\ngressive neurodegenerative disease of the human motor \nsystem, clinically characterized by upper and lower motor \nneuron dysfunction, with an incidence of 1.7/100,000 and \na median survival of approximately 5 years after diagno -\nsis [2]. Progressive bulbar palsy (PBP), or called bulbar \nphenotype ALS is mainly characterized by dysarthria \nand/or dysphagia. The median survival time of PBP was \nshorter than other subgroups. Since the patient’s ovarian \ncancer was discovered unexpectedly, the article focuses \non GOCs combined with PBP . PBP poses a great chal -\nlenge to the perioperative management of patients with \nGOCs, so the purpose of this article is to discuss the peri-\noperative management of patients with GOCs combined \nwith PBP .\nCase presentation\nA 38-year-old female is presented with a large pelvic \nmass. Gynecologic ultrasound showed a large fluid-dom -\ninated mass and measuring approximately 28.6×14.2×8.0 \ncm (Fig.  1A, B). Color Doppler ultrasound showed no \nparticular abnormal blood flow signal (Fig.  1C). Com -\nputerized tomography (CT) showed slight dilatation \nof renal pelvis and right ureter, and compression of \nadjacent intestine. The lesion size was approximately \n15.0×7.1×27.2 cm, with no significant enhancement of \nthe cystic component and more uniform enhancement of \nthe solid component (Fig.  1D-F). Carbohydrate antigen \n19-9(CA19-9) 29.20 IU/mL, remaining examination were \nnormal.\nTwo years ago, she developed pharyngeal discomfort, \nnausea while reading and brushing teeth, which gradually \nworsened. A year and a half ago, she had inflexible tongue \nmovements, slurred speech, low pitch, choking and \ncoughing. Patient did not take riluzole or other drugs. \nThe neurological examination of this hospitalization said: \npoor dysarthria, tongue muscle atrophy, eye reflexes not \nelicited, muscle strength of both upper limbs grade 5-, \nmuscle strength of both lower limbs grade 5. Pulmonary \nfunction tests were not performed because the patient \nhad puffing and leaking air. The score of Amyotrophic lat-\neral sclerosis functional rating scale revised (ALSFRS-R) \nwas 44, indicating that most of the daily activities of the \npatient were not affected. The results of the SDS depres -\nsion self-assessment scale showed a crude score of 32 and \nthe standard score was 40, indicating that the patient was \nnot depressed. The rest of the examination did not show \nany significant abnormalities.\nWith multi-disciplinary treatment (MDT) discus -\nsion before operation, the patient finally chose midline \nlaparotomy and underwent right adnexectomy under \nregional anesthesia with an epidural gap block. The \nincision reaches above the umbilicus. Intraoperatively, \natropine was used to suppress glandular secretion and \ninhibit saliva production, thereby reducing swallowing \naction. Lidocaine and ropivacaine can relieve pain, and \nthe block plane reached T10, and the VAS score of tol -\nerable pain during operation was 6. Intraoperative explo -\nration revealed no ascites in the pelvic abdomen and an \nirregular cyst in the right ovary, approximately 30 cm in \ndiameter, with an intact envelope and smooth surface. \nRight adnexal resection was performed after aspiration of \nsome intracapsular fluid by puncture. The specimen had \nsmooth walls, viscous intracapsular fluid, locally visible \ngelatinous tissue, but no cauliflower-like masses or papil -\nlae, and normal appearance of the right fallopian tube. \nDuring the operation, the patient and her family refused \nto have a complete staging operation.\nAfter operation, MDT found that the patient recov -\nered well without nausea, vomiting, cough, sputum or \ndyspnea, and a tolerable pain VAS score of 8, along with \ngood wound healing. And the symptoms of PBP did not \nworsen. The postoperative pathology suggested (right \novary) junctional mucinous tumor with some areas \nshowing mucinous carcinoma and no clear intravascular \ncarcinoma emboli: the (right) fallopian tube did not show \ncarcinoma (Fig.  2). After consultation with the patient \nand family, it was decided to surveillance. One month \nafter surgery, CA19-9 decreased to 14.50 IU/ml.\nDiscussion\nPreoperative analysis\nIt is very important to judge the benign and malignant of \nGOCs before operation. According to the tumor mark -\ners of patients, Carbohydrate antigen 125 (CA125) and \nHuman epididymal secretory protein 4 (HE4) are the \nmost valuable tumor markers applied to ovarian cysts. \nAlpha-fetoprotein (AFP) and CA19-9 is also used to \nKeywords Case report, Giant ovarian cysts (GOCs), Perioperative management, Progressive bulbar paralysis (PBP), \nPerioperative management, Multi-disciplinary treatment (MDT)\n\nPage 3 of 6\nZhang et al. BMC Women’s Health          (2024) 24:274 \n \nevaluate the nature of the tumor [3, 4]. The overall sen -\nsitivity of CA125 in differentiating benign and malignant \ntumors is 61% ~ 90%; The specificity was 71%~93%, the \npositive predictive value (PPV) was 35%~91%, and the \nnegative predictive value (NPV) was 67%~90% [5]. HE4 \nis a potential biological marker for differentiating benign \nand malignant ovarian tumors. Combined examination \nof HE4 and CA125 can further improve the sensitivity \nand specificity of diagnosis of ovarian malignant tumor \n[6]. AFP is a specific marker of ovarian endodermal sinus \ntumor and can also be used in diagnosis. The patients \nreported in this report showed no abnormality in CA125, \nHE4 and AFP , while CA19-9 was slightly elevated. \nAccording to the values of CA125 and HE4, the calcu -\nlated ROMA index is 7.341%, suggesting that ovarian \ncancer is of low risk and may be a benign tumor. Regard -\ning the risk assessment methods of benign and malignant \novarian cysts, according to the rules of the International \nOvarian Tumor Analysis Group (IOTA) [4], the rules \nconsist of five characteristics indicating malignant lesions \n(M rule) and five characteristics indicating benign lesions \n(B rule). Among them, the malignant standard (M rule) \nis multilocular cystic solid lesion (maximum diameter \n≥100mm、color score 2-3). Therefore, it has the charac -\nteristics of M and belongs to malignant tumor according \nto IOTA classification.\nFig. 1 The red arrows represent pelvic and abdominal masses, this yellow arrow represents the compressed renal pelvis and the right ureter, \nand the green arrows represent the compressed intestine. Figures A-C are gynecological ultrasound images. Figures A and B show a giant \nfluid-dominated mass from the suprapubic area between the umbilicus and the glabella, reaching the anterior axillary line on both sides, with a size \nof about 28.6×14.2 cm. Figure C: color Doppler ultrasound showed no significant abnormal blood flow signal. Figure D-F: the size of the lesion \nwas about 15.0×7.1×20.2 cm, with no significant enhancement of the cystic component and more uniform enhancement of the solid component \nafter enhancement\n\nPage 4 of 6Zhang et al. BMC Women’s Health          (2024) 24:274 \nThe neurologist needs a neurological examination, \nincluding muscle volume, muscle strength, swallow -\ning function, speech function, and respiratory function. \nALSFRSr includes four domains: medullary function, fine \nmotor function, gross motor function and respiratory \nfunction, and is an important tool for functional assess -\nment of ALS [7]. Forced vital capacity (FVC), maximum \ninspiratory pressure (MIP) can be a good measure of dia -\nphragmatic strength. In patients with advanced or med -\nullary involvement, due to difficulties in forming a tight \nseal around the mouth, collapse of the upper airway, and \nmotor defects of the airway and upper airway muscles, \nsniffing nasal inspiratory pressure (SNIP) is a good meas -\nurement tool [8].\nAnesthetic management must consider the effects \non respiratory function. It has been shown that general \nanesthesia inhibits the excitability of spinal motor neu -\nrons while depressing the respiratory system, which may \naccelerate motor neuron disease after surgery [9]. Cases \nrelated to neurological sequelae after spinal anesthesia \nhave been reported in the past, while the concentration \nof local anesthetics in the cerebrospinal fluid is much \nsmaller during epidural anesthesia, and it seems prudent \nto use epidural anesthesia [10, 11].\nThe patient’s ovarian tumor had compressed the renal \npelvis and ureter, and malignancy could not be com -\npletely ruled out, so surgery was recommended. Since the \npatient had no fertility requirements and could not toler -\nate multiple surgeries, a right ovariectomy was planned. \nBecause laparoscopic surgery requires the injection of \ncarbon dioxide (CO2) into the abdominal cavity, resulting \nin intra-abdominal pressure (IAP) of 12 to 15 mmHg, \nincreased IAP , displacement of the diaphragm cephalad, \nand decreased pulmonary compliance, this may lead to a \nventilation-perfusion mismatch, resulting in hypoxemia, \nand this is further exacerbated in the trending supine \nposition (hammerhead supine position). Abdominal dis -\ntension may also lead to pulmonary complications such \nas hypercapnia and subcutaneous emphysema [12]. If we \nchoose gasless laparoscopy, it may lead to the rupture of \ngiant ovarian cyst during the operation, which will affect \nthe prognosis. Attempted laparoscopic surgery is a great \nchallenge for PBP patients. A combined intra-neurolog -\nical and anesthetic evaluation of the patient for feasible \nsurgery resulted in the choice of transabdominal right \nadnexal resection with epidural gap block.\nPrecautions during operation\nHemodynamic instability is a worrisome complication \nof GOCs surgery. Large masses compress the vena cava, \nthereby reducing venous return, and further instability \nis caused by dilatation of the visceral vessels after mass \nresection [13, 14]. The masses should be removed slowly \nintraoperatively, and changes in blood volume should be \nclosely monitored and managed promptly.\nDuring epidural anesthesia, the plane of anesthe -\nsia should not be chosen too high (L12-S1~2 plane), \notherwise it will affect the patient’s respiratory func -\ntion, and when the patient has pain intolerance dur -\ning operation, analgesics are given promptly to relieve \npain [10]. Concerning salivation, anticholinergic drugs \nand botulinum toxin can be used to reduce glandular \nFig. 2 Postoperative pathology suggested (right ovary) junctional mucinous tumor with some areas showing mucinous carcinoma, the tumor size \nwas about 15cm×10cm×5cm, no definite intravascular carcinoma embolus was seen: (right) fallopian tube did not show carcinoma\n\nPage 5 of 6\nZhang et al. BMC Women’s Health          (2024) 24:274 \n \nsecretion [15]. The early sensitivity of percutaneous \nblood oxygen saturation measurement is poor, and \nhypoxemia cannot be detected in time and should be \njudged by the results of arterial blood gas analysis.\nIntraoperative frozen pathology should have been \nperformed according to the guidelines, but the oper -\native time in this patient should not have been too \nlong, and the false-negative rate of diagnosis based \non the absence of ascites during the operation and \nthe absence of papillary projections on the inner \nwall of the ovarian cyst, as well as mucinous ovarian \ntumors and junctional tumors usually have a high rate \nof false-negative frozen section diagnosis [1 , 3, 16]. \nAfter communication with the patient’s family, the \npatient refused to send the frozen pathology during \nthe operation.\nPostoperative management\nDysarthria and dysphagia occur in almost 80% of \npatients with medullary ALS [17]. Therefore, commu -\nnication should be done by asking more questions that \ncan be answered with yes or no. Dysphagia can lead to \naspiration and malnutrition. High-calorie and high-\nprotein oral nutritional supplements are good choices. \nEnteral nutrition is an appropriate intervention if \nthe patient has lost more than 10% of his premorbid \nweight [17].\nPBP causes weakness of the muscles of the mouth, \nface and tongue, which leads to impaired secretion \nclearance and impaired coughing, predisposes to res -\npiratory infections, and increases morbidity and mor -\ntality. Chest CT can be performed to detect pulmonary \ninfection and pulmonary atelectasis when the patient \nhas symptoms such as fever, persistent cough and \ndyspnea. Anticholinergic drugs, botulinum toxin injec -\ntions, improved overall hydration status, treatment \nwith nebulizers, and increased environmental humid -\nity all of which can help with secretion clearance.\nALS is a disease that strongly affects the psychiat -\nric aspects of patients [8 ]. Caregivers and healthcare \nprofessionals should pay real-time attention to the \npsychological status of patients and provide posi -\ntive emotional support. And that early postoperative \nactivity is beneficial to patients, so it is acceptable to \nencourage patients to move appropriately after surgery \n[18, 19].\nIn conclusion, postoperative dysphagia, secretion \nclearance, and management of respiratory function \nare crucial, and postoperative emotional management \nshould not be neglected; all postoperative conditions of \nthe patient should be closely monitored and dealt with \naccordingly in a timely manner.\nPostoperative pathological results and follow‑up \ntreatment\nPostoperative pathology reported mucinous carcinoma \nin some areas of the right ovary. Combining the patient’s \npreoperative imaging, intraoperative situation and post -\noperative pathology findings, the patient was a stage IA \novarian mucinous carcinoma according to NCCN guide -\nlines [20].\nAccording to the NCCN guidelines: Patients have the \noption of reoperation: as patients have no fertility desire, \na complete staging surgery is feasible. The procedure \nrequires resection of the entire uterus, both adnexa, \ngreater omentum, and appendix, with pelvic lymph node \nand para-aortic lymph node dissection [20, 21]. However, \nanesthesiologists assess that anesthesia for the procedure \nis difficult and extremely risky because the level of epi -\ndural anesthesia is too high and affects the patient’s res -\npiratory function, and that lymph node metastases from \novarian mucinous carcinoma are very rare. Combined \nwith the patient’s adjuvant findings, the tumor stage is \nlikely to remain unchanged after surgery [22]. The aver -\nage survival for ALS is 3-5 years [17]. Surgery is not the \nbest option for the patient, and surveillanc is chosen by \nthe patient and family after deliberation.\nConclusion\nGOCs combined with PBP is very rare. The perioperative \nmanagement of patients with GOCs combined with PBP \nrequires the combined efforts of neurologists, gynecolo -\ngists, and anesthesiologists. Preoperatively, the patient’s \nPBP progression is assessed and the anesthetic and sur -\ngical approach is felt in relation to the patient’s fertility \nrequirements, the nature of the ovarian cyst and general \ncondition. As patients with PBP mainly present with dys -\narthria and dysphagia, epidural anesthesia was chosen \nas the mode of anesthesia. Postoperative patients should \npay close attention to possible complications of ALS, \nespecially dysphagia and active respiratory function, and \ntimely carry out corresponding treatment. Also, positive \nemotional supporting is very important. Since ovarian \ncysts have the possibility of malignancy and simple resec-\ntion of ovarian cysts or unilateral adnexal resection is \nfeasible, prompt surgical treatment is recommended for \npatients with ovarian cysts combined with PBP to pre -\nvent malignancy.\nAbbreviations\nALS  amyotrophic lateral sclerosis\nGOCs  giant ovarian cysts\nPBP  progressive bulbar paralysis\nCT  computerized tomography\nCA125  carbohydrate antigen 125\nHE4  Human epididymal secretory protein 4\nAFP  Alpha-fetoprotein\n\nPage 6 of 6Zhang et al. BMC Women’s Health          (2024) 24:274 \nCA19-9  carbohydrate antigen 19-9\nFVC  Forced vital capacity\nMIP  maximum inspiratory pressure\nSNIP  sniffing nasal inspiratory pressure\nCO2  carbon dioxide\nIAP  intra-abdominal pressure\nAcknowledgements\nNot applicable.\nAuthors’ contributions\nDZ and RX: collect and sort out data and write the manuscript. TH: evaluation \nof anesthesia-related content, and writing the manuscript of anesthesia-\nrelated content. YL: Preoperative ultrasound imaging evaluation of patients. \nZH: Postoperative pathological evaluation. SY, XX, XD, LW: Participate in the \nformulation of the whole operation plan, operation and postoperative follow-\nup plan. JD: The article was finally reviewed and revised.\nFunding\nThere is no related funding.\nAvailability of data and materials\nSubmission of a manuscript to a BMC journal implies that materials described \nin the manuscript, including all relevant raw data, will be freely available to \nany scientist wishing to use them for non-commercial purposes, without \nbreaching participant confidentiality. All the data of this study are presented \nin the article, and those who need it can use it directly, as long as the source is \nindicated. If you have any questions, please contact the corresponding author, \ne-mail: dujiexian2009@163.com\nDeclarations\nEthics approval and consent to participate\nApproved by the Research Ethics Committee of the Second Hospital of Hebei \nMedical University. Reference number is 2022-R771. The informed consent of \nthe patients involved in the article has been obtained.\nConsent for publication\nPatients included in this article agree that the relevant information included \nis for publication. Informed consent to publish this information was obtained \nfrom study participant.\nCompeting interests\nThe authors declare no competing interests.\nAuthor details\n1 Department of Gynecology, The Second Hospital of Hebei Medical University, \nShijiazhuang 050000, Hebei, China. 2 Department of Gynecology, Handan first \nhospital, Handan 056000, Hebei, China. 3 Department of Anaesthesiology, First \nTeaching Hospital of Tianjin University of Traditional Chinese Medicine, Tian-\njin 300072, China. 4 Department of Ultrasound, The Second Hospital of Hebei \nMedical University, Shijiazhuang 050000, Hebei, China. 5 Department of Pathol-\nogy, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, \nHebei, China. 6 Department of Gynecology, Traditional Chinese Medicine \nHospital of Shijiazhuang, Hebei 050000, China. \nReceived: 19 November 2023   Accepted: 26 April 2024\nReferences\n 1. Jiang, L., Zhao, X., Han, Y., Liu, K., Meng, X. J. F. i. o., Giant Ovarian Cysts Treated \nby Single-Port Laparoscopic Surgery: A Case Series. 2021;11:796330.\n 2. van den Bos MAJ, Geevasinga N, Higashihara M, Menon P , Vucic S. Patho-\nphysiology and Diagnosis of ALS: Insights from Advances in Neurophysi-\nological Techniques. Int J Mol Sci. 2019;20(11):2818.\n 3. Reiser E, Pils D, Grimm C, Hoffmann I, Polterauer S, Kranawetter M, Aust S. \nDefining Models to Classify between Benign and Malignant Adnexal Masses \nUsing Routine Laboratory Parameters. Cancers. 2022;14(13):3210.\n 4. Timmerman, D.; Planchamp, F.; Bourne, T.; Landolfo, C.; du Bois, A.; Chiva, \nL.; Cibula, D.; Concin, N.; Fischerova, D.; Froyman, W.; Gallardo Madueño, \nG.; Lemley, B.; Loft, A.; Mereu, L.; Morice, P .; Querleu, D.; Testa, A.; Vergote, I.; \nVandecaveye, V.; Scambia, G.; Fotopoulou, C. J. I. j. o. g. c. o. j. o. t. I. G. C. S. \nESGO/ISUOG/IOTA/ESGE Consensus Statement on pre-operative diagnosis \nof ovarian tumors. 2021;31(7):961-982.\n 5. Dolgun ZN, Kabaca C, Karateke A, Iyibozkurt C, Inan C, Altintas AS, Karadag \nC. The Use of Human Epididymis 4 and Cancer Antigen 125 Tumor Mark-\ners in the Benign or Malignant Differential Diagnosis of Pelvic or Adnexal \nMasses. Balkan Med J. 2017;34(2):156–62.\n 6. Granato T, Porpora MG, Longo F, Angeloni A, Manganaro L, Anastasi \nE. HE4 in the differential diagnosis of ovarian masses. Clin Chim Acta. \n2015;446:147–55.\n 7. Grad LI, Rouleau GA, Ravits J, Cashman NR. Clinical Spectrum of Amyo-\ntrophic Lateral Sclerosis (ALS). Cold Spring Harb Perspect Med. 2017;7(8).\n 8. Rosa Silva JP , Santiago Junior JB, Dos Santos EL, de Carvalho FO, de Franca \nCosta IMP , Mendonca DMF. Quality of life and functional independence in \namyotrophic lateral sclerosis: A systematic review. Neurosci Biobehav Rev. \n2020;111:1–11.\n 9. Pinto S, Swash M, de Carvalho M. Does surgery accelerate progres-\nsion of amyotrophic lateral sclerosis? J Neurol Neurosurg Psychiatry. \n2014;85(6):643–6.\n 10. Gu J, Lin X. Anesthesia and postoperative analgesia for a patient with amyo-\ntrophic lateral sclerosis. Minerva Anestesiol. 2017;83(11):1216–7.\n 11. Kock-Cordeiro D., Brusse, E., van den Biggelaar R., Eggink, A., van der Marel \nC. J. I. j. o. o. a., Combined spinal-epidural anesthesia with non-invasive \nventilation during cesarean delivery of a woman with a recent diagnosis of \namyotrophic lateral sclerosis. 2018;36:108-110.\n 12. Atkinson TM, Giraud GD, Togioka BM, Jones DB, Cigarroa JE. Cardiovascu-\nlar and Ventilatory Consequences of Laparoscopic Surgery. Circulation. \n2017;135(7):700–10.\n 13. Atkinson T, Giraud G, Togioka B, Jones D, Cigarroa JJC. Cardiovascular \nand Ventilatory Consequences of Laparoscopic Surgery. Circulation. \n2017;135(7):700–10.\n 14. Van Damme L., De Waele J. J. C. c. Effect of decompressive laparotomy on \norgan function in patients with abdominal compartment syndrome: a \nsystematic review and meta-analysis. Crit Care. 2018;22(1):179.\n 15. James E, Ellis C, Brassington R, Sathasivam S, Young CA. Treatment for sialor-\nrhea (excessive saliva) in people with motor neuron disease/amyotrophic \nlateral sclerosis. Cochrane Database Syst Rev. 2022;5(5):CD006981.\n 16. Lycke M, Kristjansdottir B, Sundfeldt K. A multicenter clinical trial validating \nthe performance of HE4, CA125, risk of ovarian malignancy algorithm and \nrisk of malignancy index. Gynecol Oncol. 2018;151(1):159–65.\n 17. Burgos R, Breton I, Cereda E, Desport JC, Dziewas R, Genton L, Gomes F, \nJesus P , Leischker A, Muscaritoli M, Poulia KA, Preiser JC, Van der Marck M, \nWirth R, Singer P , Bischoff SC. ESPEN guideline clinical nutrition in neurology. \nClin Nutr. 2018;37(1):354–96.\n 18. Seeber AA, Pols AJ, Hijdra A, Grupstra HF, Willems DL, de Visser M. Advance \ncare planning in progressive neurological diseases: lessons from ALS. BMC \nPalliat Care. 2019;18(1):50.\n 19. Brent, J. R., Franz C. K., Coleman J. M., 3rd; Ajroud-Driss, S., ALS: Management \nProblems. Neurol Clin 2020;38(3)565-575.\n 20. Armstrong D. K., Alvarez R. D., Bakkum-Gamez J. N., Barroilhet L., Behbakht K., \nBerchuck A., Chen L. M., Cristea M., DeRosa M., Eisenhauer E. L., Gershenson D. \nM., Gray H. J., Grisham R., Hakam A., Jain A., Karam A., Konecny G. E., Leath C. A., \nLiu J., Mahdi H., Martin L., Matei D., McHale M., McLean K., Miller D. S, O’Malley \nD. M. Percac-Lima, S., Ratner E, Remmenga S. W., Vargas, R., Werner T. L., Zsiros, \nE., Burns, J. L., Engh, A. M., Ovarian Cancer, Version 2.2020, NCCN Clinical Prac-\ntice Guidelines in Oncology. J Natl Compr Canc Netw. 2021;19 (2):191-226.\n 21. Lokich E, Palisoul M, Romano N, Craig Miller M, Robison K, Stuckey A, DiSil-\nvestro P , Mathews C, Granai CO, Lambert-Messerlian G, Moore RG. Assessing \nthe risk of ovarian malignancy algorithm for the conservative management \nof women with a pelvic mass. Gynecol Oncol. 2015;139(2):248–52.\n 22. Heyward QD, Nasioudis D, Cory L, Haggerty AF, Ko EM, Latif N. Lymphad-\nenectomy for early-stage mucinous ovarian carcinoma. Int J Gynecol \nCancer. 2021;31(1):104–9.\nPublisher’s Note\nSpringer Nature remains neutral with regard to jurisdictional claims in pub-\nlished maps and institutional affiliations.","source_license":"CC0","license_restricted":false}