The postoperative inflammatory response to injury following laparoscopic assisted vaginal hysterectomy versus abdominal hysterectomy

C-Reactive Protein: Pathophysiology, Diagnosis, False Test Results and a Novel Diagnostic Algorithm for Clinicians

The current literature provides a body of evidence on C-Reactive Protein (CRP) and its potential role in inflammation. However, most pieces of evidence are sparse and controversial. This critical state-of-the-art monography provides all the crucial data on the potential biochemical properties of the protein, along with further evidence on its potential pathobiology, both for its pentameric and monomeric forms, including information for its ligands as well as the possible function of autoantibodies against the protein. Furthermore, the current evidence on its potential utility as a biomarker of various diseases is presented, of all cardiovascular, respiratory, hepatobiliary, gastrointestinal, pancreatic, renal, gynecological, andrological, dental, oral, otorhinolaryngological, ophthalmological, dermatological, musculoskeletal, neurological, mental, splenic, thyroid conditions, as well as infections, autoimmune-supposed conditions and neoplasms, including other possible factors that have been linked with elevated concentrations of that protein. Moreover, data on molecular diagnostics on CRP are discussed, and possible etiologies of false test results are highlighted. Additionally, this review evaluates all current pieces of evidence on CRP and systemic inflammation, and highlights future goals. Finally, a novel diagnostic algorithm to carefully assess the CRP level for a precise diagnosis of a medical condition is illustrated.

Leukocyte telomere dynamics across gestation in uncomplicated pregnancies and associations with stress

BACKGROUND

Short leukocyte telomere length is a biomarker associated with stress and morbidity in non-pregnant adults. Little is known, however, about maternal telomere dynamics in pregnancy. To address this, we examined changes in maternal leukocyte telomere length (LTL) during uncomplicated pregnancies and explored correlations with perceived stress.

METHODS

In this pilot study, maternal LTL was measured in blood collected from nulliparas who delivered live, term, singleton infants between 2012 and 2018 at a single institution. Participants were excluded if they had diabetes or hypertensive disease. Samples were collected over the course of pregnancy and divided into three time periods: < 200/7 weeks (Timepoint 1); 201/7 to 366/7 weeks (Timepoint 2); and 370/7 to 9-weeks postpartum (Timepoint 3). All participants also completed a survey assessing a multivariate profile of perceived stress at the time of enrollment in the first trimester. LTL was measured using quantitative polymerase chain reaction (PCR). Wilcoxon signed-rank tests were used to compare LTL differences within participants across all timepoint intervals. To determine whether mode of delivery affected LTL, we compared postpartum Timepoint 3 LTLs between participants who had vaginal versus cesarean birth. Secondarily, we evaluated the association of the assessed multivariate stress profile and LTL using machine learning analysis.

RESULTS

A total of 115 samples from 46 patients were analyzed. LTL (mean ± SD), expressed as telomere to single copy gene (T/S) ratios, were: 1.15 ± 0.26, 1.13 ± 0.23, and 1.07 ± 0.21 for Timepoints 1, 2, and 3, respectively. There were no significant differences in LTL between Timepoints 1 and 2 (LTL T/S change - 0.03 ± 0.26, p = 0.39); 2 and 3 (- 0.07 ± 0.29, p = 0.38) or Timepoints 1 and 3 (- 0.07 ± 0.21, p = 0.06). Participants who underwent cesareans had significantly shorter postpartum LTLs than those who delivered vaginally (T/S ratio: 0.94 ± 0.12 cesarean versus 1.12 ± 0.21 vaginal, p = 0.01). In secondary analysis, poor sleep quality was the main stress construct associated with shorter Timepoint 1 LTLs (p = 0.02) and shorter mean LTLs (p = 0.03).

CONCLUSIONS

In this cohort of healthy pregnancies, maternal LTLs did not significantly change across gestation and postpartum LTLs were shorter after cesarean than after vaginal birth. Significant associations between sleep quality and short LTLs warrant further investigation.

Antidepressant and Anxiolytic Effects and Subacute Toxicity of the Aerial Parts of Psychotria ankasensis J.B.Hall (Rubiaceae) in Murine Models

Background

The present study aimed at validating the traditional use and toxicity profile of a methanolic extract of the aerial parts of Psychotria ankasensis in alleviating depression and anxiety disorders.

Method

The antidepressant effect of methanolic extract of Psychotria ankasensis (PAE 30, 100, and 300 mg/kg, p.o.) was assessed in mice using the forced swim test (FST) and the tail suspension test (TST). The plant's anxiolytic potential was also evaluated in mice using the elevated plus-maze (EPM) and the open field tests (OFT). The subacute toxicity was assessed via oral administration of PAE at doses of 100, 300, and 1000 mg/kg in rats for 28 days.

Results

PAE 100 and 300 mg/kg showed antidepressant-like properties by significantly (at least p < 0.05) decreasing the frequency and duration of immobility in FST and TST. PAE (100 and 300 mg/kg) also showed a significant (at least p < 0.05) anxiolytic effect in both EPM and OFT. In the EPM test, E_max for PAE and diazepam were 92.52 ± 40.11% and 85.95 ± 45.92%, respectively, whereas E_max was approximately 100% for both test drugs in the OFT. Subacute administration of PAE did not reveal any toxic effects with respect to organ weight index, haematological, serum biochemical, and histopathological parameters.

Conclusions

Methanolic extract of P. ankasensis exhibited antidepressant-like and anxiolytic-like effects devoid of significant toxicity at the doses tested in murine models.

Two cases of giant peritoneal inclusion cysts requiring treatment after total laparoscopic hysterectomy

Peritoneal inclusion cysts (PICs) often develop in post-operative patients. Since the incidence of adhesions is lower with laparoscopic surgery than with open surgery, PICs are less likely to occur in the former. Although post-operative adhesions or PICs rarely develop after laparoscopic surgery (such as total laparoscopic hysterectomy: TLH), we encountered two cases of giant PICs with abdominal pain after TLH. In Case 1, strong adhesion was already present when TLH was performed. Therefore, this case may have been predisposed to the development of adhesions in the abdominal cavity. However, no adhesions were observed during TLH in case 2, and there were no risk factors, such as pre-operative adhesions and endometriosis. Therefore, adhesions and PICs may develop even after TLH, and approaches need to be considered for their prevention.

A comparative study of autologous rectus fascia pubovaginal sling surgery and synthetic transobturator vaginal tape procedure in treatment of women with urodynamic stress urinary incontinence

OBJECTIVE

To compare short term results of autologous rectus fascia pubovaginal sling surgery with synthetic transobturator vaginal tape procedure in treatment of female stress urinary incontinence (SUI) STUDY DESIGN: It was a comparative study on 30 women between 25-65 years of age with urodynamic proven SUI who were randomly allocated to autologous rectus fascia pubovaginal sling surgery (Group I)(15 women) and synthetic transobturator vaginal tape procedure (Group II) (15 women). Preoperative and postoperative ICIQ (International Consultation on Incontinence Questionnaire) score, urodynamic study and serum CRP and IL-6 were done in all cases.

RESULTS

The baseline characteristics in terms of age, body mass index (BMI), parity, mean ICIQ score and mean preoperative CRP and IL-6 levels were similar in two groups. Mean operative time was significantly longer (55.60 ± 5.77 vs 25.27 ± 4.32 minutes, p = 0.001) in group I than group II. Mean hospital stay of 7.1 ± 1.2 vs 1.2 ± 0.4 days, mean duration of catheterization 5.8 vs 1.2 day (<0.01) and postoperative urinary retention requiring recathterization were all significantly higher in group I than II. Wound infection was more in group I than in group II (p = 0.01) while groin pain was significantly more in group II (p = 0.01). One patient developed vesicovaginal fistula, while one patient required cutting of tape in group I. Pdet at Q max (Detrusor pressure at peak urine flow) increased significantly in both the groups after surgery. ICIQ score was zero in both the groups indicating 100 % success. Surgical trauma was more in group I as shown by significantly higher CRP levels.

CONCLUSION

The success rate of the two groups was similar but, autologous rectus fascia sling surgery took longer, had more complications and urinary retention as compared to transobturator vaginal tape procedure.

Assessing trends in laparoscopic colostomy reversal and evaluating outcomes when compared to open procedures

BACKGROUND

Laparoscopic colostomy reversal has emerged as a viable option for Hartmann's reversal but the trends in national adoption and postoperative complications are unknown. This study evaluates the practice trends for laparoscopic colostomy and compares complications, length of stay, and operative times between laparoscopic and open colostomy reversal.

METHODS

All patients who had open or laparoscopic colostomy reversal surgery (current procedure codes: 44227 and 44626) between 2005 and 2014 were identified from the American College of Surgeons National Surgical Quality Improvement Program. Data collected included patient demographics, comorbid conditions, postsurgical diagnosis, and estimated probabilities of morbidity and mortality. Univariate and multivariate unconditional logistic regression models and linear regression models were employed to evaluate the associations between various outcomes and surgical specialties.

RESULTS

The reported volume of both open and laparoscopic colostomy reversal surgeries increased over time, but the percentage of open reversal surgery decreased from 100% in 2005 to 74.2% in 2014. The average annual increase in percentage of laparoscopic colostomy reversal surgery was 2.87%. The complication rates of open colostomy reversal surgery were significantly higher than the rates of laparoscopic colostomy reversal surgery (P < 0.0001). Although there were fluctuations, the complication rates remained constant over the 9-year study period for both open and laparoscopic colostomy reversal surgeries. The total hospital length of stay among patients who had laparoscopic colostomy reversal surgery was shorter compared to patients who had open colostomy reversal surgery [mean change (MC) = -1.77 days, P < 0.0001]. Similarly, a shorter operation time was also observed for patients who had laparoscopic colostomy reversal surgery (MC = -26.48 min, P < 0.0001).

CONCLUSION

Based on the NSQIP database, laparoscopic colostomy reversal is increasing steadily year over year from 2005 to 2014 in NSQIP participating hospitals. Overall complication rates and length of stay are significantly lower and sustained throughout the study period for laparoscopic reversal.

Comparison of total laparoscopic hysterectomy and abdominal hysterectomy

Objective:

The aim of this prospective study is to evaluate and compare to the outcomes of total laparoscopic hysterectomy (TLH) and total abdominal hysterectomy (TAH) who performed in our clinic.

Materials and Methods:

We performed surgical procedures at Necmettin Erbakan University Faculty of Medicine, Department of Obstetrics and Gynecology between January 2013 and April 2014. Forty patients who underwent TLH (group 1) compared to 40 patients who underwent TAH (group 2). The mean age of the cases, body mass index (BMI), duration of operation, the amount of blood loss, rates of complications and post operative hospital stay were compared for two groups.

Results:

There were no statistically significant differences between the two groups regarding age, body mass index (BMI), specimen weight, pre-operative hemoglobin (Hb) value and rates of the complications. The mean post-operative Hb value was significantly higher in group 1 than group 2 (11.5±0.8 gr/dl vs. 10.8±1.7, p=0.02). The mean time of operation was significantly longer in group 1 than in group 2 (105.4±22.9 minutes vs. 74±18, p<0.001). The mean duration of hospital stay was statistically shorter in group 1 compared to the group 2 (2.48±0.6 days vs. 4.88±1.2, p<0.001).

Conclusion:

Total laparoscopic hysterectomy is safe and feasible method for gynecological diseases. TLH may offer specific benefits for properly selected patients. Its advantages are lower peri-operative morbidity, improvement of quality of life, shorter hospital stay and faster return to activity.

Correlation of interleukin-6, serum lactate, and C-reactive protein to inflammation, complication, and outcome during the surgical course of patients with acute abdomen

In the present scenario, doctors have to rely on radiological methods for diagnosis of acute abdomen in addition to their clinical skill. The use of serum markers for assessing the outcome of such patients is still debatable. Our aim was to evaluate whether the combined use of serum lactate, interleukin (IL)-6, and C-reactive protein (CRP) is able to simultaneously establish both the septic status and the prognosis of acute abdomen. Ninety-nine patients undergoing surgery for acute abdomen were taken up for the study. The patients were divided into 4 groups based on the level of sepsis. Serum lactate, IL-6, and CRP were determined in the serum of all the subjects. It was found that serum lactate determination, using the cutoff value < 3.9 mM, had a high sensitivity (100%) and specificity (83%) in differentiating patients with severe sepsis from those with sepsis. IL-6 came next with a sensitivity of 87% and a specificity of 81%. The AUC for serum lactate (0.922), IL-6 (0.912), and CRP (0.719) in differentiating between patients with severe sepsis and those with sepsis also proves the superiority of serum lactate and IL-6. The combined use of serum lactate and IL-6 would allow us to simultaneously establish the prognosis of patients with acute abdomen (r(2) = 0.368, P = 0.008). The combined use of serum lactate and IL-6 is useful in simultaneously establishing both the severity of sepsis and, hence, the prognosis of acute abdomen.

Indication for laparoscopically assisted vaginal hysterectomy

When uterine weight is greater than 800 grams, total abdominal hysterectomy is more appropriate than laparoscopic-assisted vaginal hysterectomy.

Objectives:

Total hysterectomy procedures include total abdominal hysterectomy (TAH), total vaginal hysterectomy (TVH), and laparoscopically assisted vaginal hysterectomy (LAVH). Our institution has introduced LAVH as a preferred option to the more invasive TAH. To date, no reports have proposed surgical indications for LAVH based on statistical analysis of surgical results. The purpose of this study was to establish criteria for performing LAVH through statistical analysis of a retrospective review of surgical outcomes in LAVH cases at our institution over a period of 15 years.

Methods:

The medical records of 629 patients scheduled for LAVH for uterine fibroids and/or adenomyosis at our hospital were examined. Surgical results (blood loss, operative time, rates of conversion to laparotomy, and intra- and postoperative complications) were compared among 9 groups classified by uterine weight.

Results:

Statistically significant differences in surgical outcomes were found between the group with a uterine weight ≥800g and the other groups.

Conclusion:

We found that when the uterine weight was ≥800g, TAH was more appropriate because significant blood loss and/or complications would be expected during LAVH. A removed uterus weighing 800g is reportedly equivalent to a preoperative uterine size of approximately 12cm. Therefore, LAVH may be safely indicated for patients with a uterine size ≤12cm (approximately equivalent to the uterine size at 16-weeks gestation).

Total abdominal hysterectomy versus laparoscopically-assisted vaginal hysterectomy versus total vaginal hysterectomy

INTRODUCTION

While total abdominal hysterectomy (TAH) and total vaginal hysterectomy (TVH) are conventional procedures, we have actively introduced laparoscopically-assisted vaginal hysterectomy (LAVH) since its advent. This study was the first attempt to retrospectively compare the surgical results, including invasiveness, among the three methods of performing a hysterectomy.

METHODS

The subjects included 1181 patients who underwent total hysterectomies (TAH, n=465; LAVH, n=629; TVH, n=87) due to uterine fibroids or uterine adenomyosis at our hospital between January 1995 and December 2009. The mean age, parity, weight of the removed uterus, operative time, blood loss, rates of intra- and post-operative complications, length of post-operative hospital stay, leukocyte count, and CRP and hemoglobin levels were compared.

RESULTS

The operative time was significantly longer in the LAVH group than the other two groups. Blood loss was significantly greater in the TAH group than the LAVH and TVA groups. The rates of intra- and post-operative complications were significantly higher in the TAH group than the LAVH group. The CRP level and leukocyte count were significantly lower in the LAVH group than the TAH and TVH groups.

CONCLUSION

LAVH can be applied to nulligravidas or patients with relatively large uteri and it is proved less invasive than TAH and TVH in this study. We recommend active application of LAVH.

Role of serum interleukin-6 in comparing surgical stress after laparoscopic-assisted vaginal hysterectomy and non-descent vaginal hysterectomy for large uteri

AIMS AND OBJECTIVES

To compare the perioperative inflammatory response using interleukin-6 (IL-6) in patients of laparoscopic-assisted vaginal hysterectomy (LAVH) and non-descent vaginal hysterectomy (NDVH) for large uteri with benign disease.

MATERIALS AND METHODS

Twenty women with benign uterine disease and failed medical management with size of uterus ranging from 300 to 1,500 g (12-24 weeks) were randomized into two equal groups for either technique of hysterectomy, LAVH and NDVH. Venous blood levels of IL-6 were measured preoperatively and 3, 24 and 72 h after beginning of surgery. Statistical analysis was done using SPSS15 software.

RESULTS

No statistically significant difference was present in demographic characteristics, operating time, and uterine weight between the two groups. No major complications were encountered. The increase in serum interleukin 6 levels from preoperative value to the value at 3 h postoperatively was found to be significantly higher in LAVH group when compared with NDVH group indicating greater tissue handling and trauma in LAVH group.

CONCLUSION

Non-descent vaginal hysterectomy appears to be better than laparoscopic-assisted vaginal hysterectomy for large uteri in terms of inflammatory response.

The immunomodulatory effects of laparoscopic surgery

Laparoscopic alternatives to conventional surgical procedures confer many advantages to patients including reduced postoperative pain, shortened convalescence and, perhaps, improved disease-related outcomes. The diminished degree of immune dysfunction apparent with these techniques may underpin these beneficial aspects. However, minimal access is accompanied by various ancillary anesthetic and mechanical associations (including the induction of a carbon dioxide pneumoperitoneum), which must be considered in addition to reduced tissue trauma when attempting to correlate cause with effect. Furthermore, the opportunity to establish causation between the immunomodulatory aspects of laparoscopy and subsequent clinical outcome by prospective, randomized study is difficult because of the rapid incorporation of minimal access techniques into clinical practice. Therefore, experimental in vitro and in vivo studies must be used to complement the limitations of clinical studies in this area. Although the initial investigations into the immunological effects of laparoscopy are encouraging, many of the intricacies associated with this approach still await elaboration.

Cytokine response in the postoperative period after surgical treatment of benign adnexal masses: comparison between laparoscopy and laparotomy

BACKGROUND

Cytokines are the main mediators of the inflammation and the response to trauma. The purpose of the present study was the comparative assessment in sera of patients with benign adnexal masses treated by laparoscopy or laparotomy of the following proinflammatory and anti-inflammatory cytokines: interleukin (IL)-1beta, IL-6, IL-8, tumor necrosis factor-alpha (TNF-alpha), and IL-10 in the early postoperative period.

METHODS

A total of 40 patients with benign adnexal masses were studied; 25 of whom underwent laparoscopy and 15, laparotomy. Blood serum concentration of IL-1beta, IL-6, IL-8, TNF-alpha, and IL-10 were measured by commercially available ELISA assays before and 4 h, 24 h, and 48 h after the operation.

RESULTS

Concentrations of IL-6 were significantly increased in both groups at 4 h, 24 h, and 48 h after the surgery; levels of IL-10 showed a significant increase 4 h and 24 h after the operation; an increase in IL-1beta levels was observed only after laparotomy; no significant variations were observed in serum levels of IL-8; the postoperative increase of IL-1beta, IL-6, and IL-10 levels was more pronounced in patients undergoing laparotomy than in those treated laparoscopically; length of the surgical procedure, amount of CO2 used, tumor diameter, age, and body mass index (BMI) of the patients did not influence the postoperative patterns of the studied cytokines.

CONCLUSIONS

Systemic cytokine response after operations for benign adnexal masses depends on the degree of the surgical trauma, and is less pronounced in patients undergoing laparoscopy.

Increased plasma interleukin 6 concentrations and exaggerated adipose tissue interleukin 6 content in severely obese patients after operative trauma

BACKGROUND

The cytokine response to operative trauma may be altered in obesity. Thus, we monitored changes in systemic and adipose tissue content of interleukin 6 (IL-6) and in insulin resistance in nonobese versus severely obese patients before and immediately after abdominal operations.

METHODS

At the beginning and the end of operation, blood samples and biopsies consisting of visceral adipose tissue (VAT) and subcutaneous adipose tissue (SAT) were collected from 13 nonobese and 33 severely obese patients. Systemic concentrations of glucose, insulin, and IL-6, as well as adipose tissue content of IL-6, were determined.

RESULTS

Plasma IL-6 concentration and adipose tissue content of IL-6 increased, compared with baseline in patients after operation (plasma, 13- and 5.7-fold; VAT, 270- and 210-fold; SAT, 79- and 8.2-fold in severely obese vs nonobese patients, respectively). The increase in IL-6 in plasma and in both VAT and SAT was exaggerated in severely obese patients, compared with nonobese patients. Increases after operation in plasma IL-6 concentrations were correlated positively to the corresponding increases in both SAT and VAT IL-6 content (r = 0.57 and 0.66, respectively). Also, we found a positive correlation between the worsening of insulin resistance and increases in both plasma and SAT IL-6 concentrations (r = 0.40 and 0.51, respectively).

CONCLUSIONS

Circulating IL-6 concentrations both at baseline and after operation are related strongly to abdominal adipose tissue content of content of IL-6 and are exaggerated in severely obese persons. After operation, worsening of insulin resistance is associated with increasing plasma and adipose tissue content of IL-6.

Endoscopy teaching in Canada: A survey of obstetrics and gynecology program directors and graduating residents

OBJECTIVE

To examine the current state of basic and advanced gynecologic endoscopy teaching in Canadian Obstetrics and Gynecology (Ob/Gyn) residency programs.

METHODS

On Institutional Research Board approval, 2 pretested anonymous questionnaires were developed: one distributed to all Canadian Ob/Gyn program directors and a second to graduating residents (Canadian Task Force classification III). Two mailings were sent to maximize response, and some department chairs received personal telephone calls by the senior author to encourage participation. Residents on maternity leave were excluded from the study.

RESULTS

Fifteen of 16 (94%) program directors, and 47 of 62 (76%) residents participated. Directors expect all residents to be knowledgeable and competent performing basic endoscopic procedures on graduation. However, considerable variation exists among programs that teach advanced endoscopy. Some of the more important factors limiting integration of advanced endoscopic teaching include paucity of trained faculty, lack of attending interest, scarcity of operating time, and financial constraints. Most graduating residents consider undertaking additional gynecologic endoscopy fellowships.

CONCLUSION

Most Ob/Gyn program directors and graduating residents consider endoscopic surgery essential to contemporary practice. There is consensus to improve resident teaching in gynecologic endoscopy and commitment to better prepare future practitioners to ensure patient safety. Paucity of trained faculty and fiscal constraints appear to be important limiting factors.

Tissue Trauma in Abdominal and Laparoscopic-Assisted Vaginal Hysterectomy

STUDY OBJECTIVE

To compare the degree of tissue damage between abdominal and laparoscopic-assisted hysterectomy.

DESIGN

Prospective, randomized, controlled study (Canadian Task Force classification I).

SETTING

University hospital.

PATIENTS

Forty-six women.

INTERVENTION

Laparoscopic-assisted and abdominal hysterectomy.

MEASUREMENTS AND MAIN RESULTS

The degree of tissue injury caused by surgical trauma was assessed by measuring plasma levels of creatine phosphokinase (CPK), C-reactive protein (CRP), lactic dehydrogenase (LDH), and CA 125 in patients undergoing laparoscopic-assisted (n = 23) and abdominal hysterectomy (n = 23). Plasma levels of CPK-MB isoenzyme were measured in order to exclude the possibility of myocardial injury. Blood samples were taken preoperatively, and on the first and second postoperative days. There was no difference in demographic characteristics between the groups. One patient in the laparotomy group and two patients in the laparoscopy group were excluded from analysis due to bladder injury, postoperative thrombophlebitis, and conversion to laparotomy because of severe adhesions. The mean operation time was longer (105.5 +/- 23.1 minutes vs 77.3 +/- 18.7 minutes, p < .001), but the duration of hospital stay was shorter (2.7 +/- 0.8 days vs 4.3 +/- 1.4 days, p < .001) and analgesic requirement was lower in the laparoscopy group compared with the abdominal group. We observed significant postoperative increases in CRP and CPK in both groups on postoperative days 1 and 2, whereas the increase in LDH was significant only in the laparotomy group on postoperative day 2. There were no significant changes in CPK-MB and CA 125. Moreover, mean plasma levels of CRP and CPK were significantly higher in the laparotomy group on postoperative days 1 and 2 than in the laparoscopy group (p < .05).

CONCLUSION

Surgery is a significant cause of tissue injury that can be assessed by specific enzymes and proteins. We suggest that laparoscopic surgery causes less tissue damage as assessed by lower postoperative CRP and CPK values, and that less tissue trauma related with laparoscopic surgery may account for early mobilization and reduced analgesic requirement in these patients.

Tissue trauma after vaginal hysterectomy and colporrhaphy versus abdominal hysterectomy: A randomised controlled study

OBJECTIVE

As the magnitude of tissue trauma can be detected by measuring the blood levels of acute phase reactants, we aimed to evaluate tissue trauma markers after abdominal hysterectomy (AH) and vaginal hysterectomy (VH). We hypothesised that VH will be associated with a reduced increase in the level of acute phase reactants than AH.

METHODS

Thirty women out of 92 patients scheduled for hysterectomies between June 2002 and June 2003 were randomised into two equal groups (n = 15) of VH and AH. Their levels of C-reactive protein (CRP), alpha1-antitrypsin (alpha1-AT) and myoglobin (M) were analysed preoperatively and on the second, fourth and sixth days.

RESULTS

In both methods of hysterectomy, the operating time (85.3 +/- 6.57 min in the VH group vs 69 +/- 7.54 min in the AH group, P < 0.0001), and hospital stay duration (7.2 +/- 2.5 days in the AH group, 3.1 +/- 1.1 days in the VH group, P < 0.0001) were highly significantly different from each other. Demographic parameters and other parameters which may affect tissue trauma markers were not statistically significantly different in each group. Postoperative increases in all markers were markedly high and showed a high statistical difference in both groups (P < 0.05). The postoperative CRP and M values in both groups were significantly higher in the AH group on the second and fourth days and on the sixth day for M only, whereas alpha1-AT levels were only statistically different on the second day. The tissue trauma markers returned to normal levels on the sixth postoperative day for M, although there still was a statistically significant difference, but remained higher than normal for alpha1-AT and CRP.

CONCLUSION

Whenever possible, VH should replace AH because this technique leads to a shorter hospital stay and less tissue trauma, enabling patients to return to their normal lives.

A randomized study of total abdominal, vaginal and laparoscopic hysterectomy

OBJECTIVES

To evaluate operative time, blood loss and inflammatory response in patients submitted to hysterectomy.

METHODS

Sixty patients referred for hysterectomy were prospectively randomized to total abdominal hysterectomy (n=20), vaginal hysterectomy (n=20), or laparoscopic hysterectomy (n=20). The operative time, blood loss (variation in erythrocyte and hemoglobin) and inflammatory answer (CRP and interleukin-6 dosages) were compared by using Kruskal-Wallis, Dunn non-parametric test and variance analysis with repeated measurements.

RESULTS

Operative time was shorter for vaginal hysterectomy, and there was no significant difference between total abdominal hysterectomy and laparoscopic hysterectomy. Reduction in erythrocyte and hemoglobin was more noticeable after vaginal hysterectomy, followed by total abdominal hysterectomy and laparoscopic hysterectomy. CRP levels increased steadily from vaginal hysterectomy to laparoscopic hysterectomy and then to total abdominal hysterectomy. The increase in interleukin-6 was substantially higher in total abdominal hysterectomy, whereas no difference was noted between vaginal and laparoscopic hysterectomy.

CONCLUSIONS

Vaginal hysterectomy presents superior results in terms of operative time and inflammatory response when compared with total abdominal and laparoscopic hysterectomy and it should be the first option for hysterectomy. Laparoscopic hysterectomy should be considered when the vaginal approach is unfeasible, showing clear advantages over abdominal hysterectomy.

C-reactive protein should accelerate the diagnosis of bowel injury after gynecologic surgery

STUDY OBJECTIVE

To search for a marker that could aid in earlier diagnosis of bowel injury after gynecologic surgery.

DESIGN

Retrospective case study with prospective controls (Canadian Task Force classification II-2).

SETTING

University hospital.

PATIENTS

Fourteen women with bowel injuries and 50 controls with no postoperative complications.

MEASUREMENTS AND MAIN RESULTS

Bowel injury occurred in 14 (2.4/1000) of 5901 gynecologic procedures. Of these, eight were recognized intraoperatively and treated immediately. In six women C-reactive protein levels were markedly increased (>100 mg/L) relative to control patients (p <0.0001).

CONCLUSION

Systematic postoperative assessment of C-reactive protein in patients at high risk for bowel injury may help identify this complication earlier in the postoperative period.

Indomethacin attenuates the immunosuppressive and tumor-promoting effects of surgery

We have previously shown in rats that both intrathecal and systemic analgesia regimens attenuate surgery-induced increases in tumor susceptibility. The current study used indomethacin to assess the role of prostaglandins and inflammation-associated pain in mediating the deleterious effects of surgery on immunity and tumor susceptibility. Male and female Fischer 344 rats were anesthetized with halothane and were either subjected or not to experimental laparotomy, followed by the administration of indomethacin or vehicle. Tumor susceptibility was assessed by the lung retention assay using the syngeneic MADB106 mammary adenocarcinoma cell line, a natural killer (NK)-sensitive tumor that colonizes only in the lungs. Surgery resulted in a 2- to 3.5-fold increase in lung tumor retention, and indomethacin administration significantly reduced this effect in both sexes without affecting unoperated animals. Indomethacin also attenuated the reductions in rearing behavior evident after surgery, suggesting that it relieved abdominal discomfort. Surgery increased interleukin-6 levels and suppressed NK activity per milliliter blood. Indomethacin restored NK activity in both male and female rats but attenuated surgery-induced interleukin-6 increases only in the male rats. These findings further support our previous work implicating pain in mediating the tumor-enhancing effects of surgery and implicate prostaglandins in mediating this effect. If similar relationships occur in humans, controlling postoperative pain and inflammation must become a priority in the management of cancer patients undergoing surgery.

Laparoscopically assisted vaginal and abdominal hysterectomy: comparison of postoperative pain, fatigue and systemic response. A case-control study

BACKGROUND AND OBJECTIVE

Laparoscopic and open surgery have been compared with conflicting results regarding their systemic responses. The sensitivity of biochemical markers that are used to discriminate between the stress responses to different types of surgery varies from study to study. We wanted to evaluate the stress response and the sensitivity of clinical and biochemical stress markers in patients undergoing laparoscopically assisted vaginal or abdominal hysterectomy.

METHODS

We performed a case-control study with patients undergoing laparoscopically assisted vaginal hysterectomy (n=20) or abdominal hysterectomy (n=20). Pain scores were assessed at rest and during coughing, and active leg elevation and fatigue scores using a visual analogue scale. In 10 patients of each group, haematocrit, white cell count, C-reactive protein, glucose, cortisol, adrenocorticotrophic hormone, beta-endorphin immunoreactivity, interleukin-6 and urine excretion of epinephrine and norepinephrine were measured preoperatively and during the first 44 postoperative hours.

RESULTS

The most sensitive symptoms and markers of the systemic response were pain scores during mobilization, fatigue scores, C-reactive protein and interleukin-6 (P < 0.01 in all comparisons). Pain scores at rest, and all other laboratory markers of the systemic response, did not discriminate between the two types of surgery.

CONCLUSION

Follow-up of postoperative pain scores during mobilization and fatigue levels might be an easy tool for the evaluation of postoperative recovery. Using an identical anaesthetic technique, the neuroendocrine response was of the same magnitude after both types of surgery.

Prospective evaluation of the systemic immune response following abdominal, vaginal, and laparoscopically assisted vaginal hysterectomy

BACKGROUND

Alterations in serum levels of cytokine interleukin-6 (IL-6) and acute-phase protein C-reactive protein (CRP) correlate directly with extent of tissue damage and inflammatory reaction. We therefore prospectively compared the postoperative levels of IL-6 and CRP following abdominal (AH), vaginal (VH), and laparoscopically assisted vaginal hysterectomy (LAVH).

METHODS

A total of 29 patients were included in the study (10 VH, 10 LAVH, 9 AH). Nine blood samples were taken from each patient at various time points before, during, and after surgery. CRP and IL-6 were measured under standardized conditions using ELISA and turbidometry.

RESULTS

Preoperative levels of IL-6 and CRP were low in all three patient groups. There was a significant increase in the IL-6 level in patients undergoing AH at the time of peritoneal closure that reached a maximum 2 h postoperatively and remained significantly elevated for 12 h postoperatively when compared to the IL-6 levels of patients undergoing VH or LAVH (p < 0.05). The levels of the IL-6 time courses differed significantly among the three operative procedures (p = 0.013). In contrast, the levels of the CRP time courses did not differ significantly (p = 0.066); however, CRP expression was elevated 36 h postoperatively in patients undergoing AH, as compared with those undergoing VH.

CONCLUSION

Elevated IL-6 levels subsequent to AH may reflect significantly greater tissue damage in these patients than in patients who undergo VH or LAVH. LAVH should therefore be considered in cases that cannot be managed by the vaginal route alone.

Percutaneous necrosectomy and sinus tract endoscopy in the management of infected pancreatic necrosis: an initial experience

OBJECTIVE

To describe the development of a minimally invasive technique aimed at surgical debridement in addition to simple drainage of the abscess cavity.

SUMMARY BACKGROUND DATA

Surgical intervention for secondary infection of pancreatic necrosis is associated with a death rate of 25% to 40%. Although percutaneous approaches may drain the abscess, they have often failed in the long term as a result of inability to remove the necrotic material adequately.

METHODS

Fourteen consecutive patients with infected necrosis secondary to acute pancreatitis were studied. The initial four patients underwent sinus tract endoscopy along a drainage tract for secondary sepsis after prior open necrosectomy. This technique was then modified to allow primary debridement for proven sepsis to be carried out percutaneously in a further 10 patients. The techniques and initial results are described.

RESULTS

Additional surgery for sepsis was successfully avoided in the initial four patients managed by sinus tract endoscopy, and none died. Of the following 10 patients managed by percutaneous necrosectomy, 2 died. The median inpatient stay was 42 days. There was one conversion for intraoperative bleeding. Eight patients recovered and were discharged from the hospital after a median of three percutaneous explorations. Only 40% of patients required intensive care management after surgery.

CONCLUSIONS

These initial results in an unselected group of patients are encouraging and show that unlike with percutaneous or endoscopic techniques, both resolution of sepsis and adequate necrosectomy can be achieved. The authors' initial impression of a reduction in postoperative organ dysfunction is particularly interesting; however, the technique requires further evaluation in a larger prospective series.

Reducing costs of laparoscopic hysterectomy

STUDY OBJECTIVE

To establish the role of laparoscopic hysterectomy using reuseable surgical equipment.

DESIGN

Prospective, observational study (Canadian Task Force classification II-2).

SETTING

Tertiary major teaching hospital.

PATIENTS

Fifty consecutive women carefully selected for laparoscopic hysterectomy.

INTERVENTIONS

The ultrasonically activated (harmonic) scalpel was used for coagulative cutting of pedicles and ligaments attached to the uterus and adnexa, backed by bipolar diathermy. No nonabsorbable material was left in the pelvis at the conclusion of the procedures.

MEASUREMENTS AND MAIN RESULTS

Patient characteristics, uterine weight, histology, operating time, recovery, analgesic requirements, and hospital stay were recorded. Complications were noted and critically assessed for constructive quality assurance appraisal. Outcomes were satisfactory according to both patients and gynecologists.

CONCLUSION

This pilot study suggests that the method is an efficacious, cost-effective, and well-controlled technique of laparoscopic hysterectomy.

Simultaneous Serum Assays of Lipase and Interleukin-6 for Early Diagnosis and Prognosis of Acute Pancreatitis

Background: There are no systems for the rapid diagnosis and prognosis of acute pancreatitis in the Emergency Department. Our aim was to evaluate whether the combined use of serum lipase and interleukin-6 or serum lipase and C-reactive protein is able to simultaneously establish both the diagnosis and the prognosis of acute pancreatitis.

Methods: Eighty patients with acute abdomen were studied on admission to the Emergency Room. Forty patients had nonpancreatic acute abdomen, and 40 had acute pancreatitis (25 had mild acute pancreatitis and 15 had severe pancreatitis). Forty healthy subjects comparable for sex and age were also studied as controls. Lipase, interleukin-6, and C-reactive protein were determined on serum in all subjects.

Results: Using lipase to discriminate between patients with nonpancreatic acute abdomen and patients with acute pancreatitis (cutoff values ranging from 419 to 520 U/L), one patient with acute pancreatitis was not identified correctly. To discriminate between patients with severe acute pancreatitis and those with mild pancreatitis in the remaining 39 patients, interleukin-6 (cutoff value, &lt;3.7 μg/L) had a sensitivity of 100% (15 of 15) and a specificity of 83% (20 of 24); 75 of 80 (94%) patients were classified correctly. C-reactive protein (cutoff values ranging from 6 to 7 mg/L) showed a lower prognostic efficiency than interleukin-6: sensitivity of 87% (13 of 15) and specificity of 46% (11 of 24). Sixty-four of 80 patients (80%) were classified correctly. The area under the ROC curve for interleukin-6 (0.911 ± 0.049) was significantly (P = 0.013) greater than that for C-reactive protein (0.685 ± 0.090).

Conclusion: The combined use of serum lipase and interleukin-6 is useful in simultaneously establishing both the diagnosis and the prognosis of acute pancreatitis.