The influence of persistent bleeding after supracervical hysterectomy on depressive and anxious symptoms: a prospective bicenter study

PURPOSE

Postoperative spotting is a frequent adverse symptom after laparoscopic supracervical hysterectomy (LSH). The conical excision (eLSH) reduces the postoperative spotting rate, but data in a larger collective are still rare and inconsistent. The influence of persistent bleeding on the anxious and depressive symptoms has not been analyzed yet.

METHODS

311 patients, who underwent a laparoscopic supracervical hysterectomy with conical excision (n = 163), or with straight cervical resection (n = 148) were included. Anxious and depressive symptoms and postoperative spotting were recorded before operation, at 3 month follow-up and at 1 year follow-up in both operative groups using a validated questionnaire (German version of Hospital Anxiety and Depression Scale, HADS-D) and additional questions concerning the frequency and impact of bleeding. Statistical analysis included the impairment of bleeding as well as its impact on depressive and anxious symptoms for both groups.

RESULTS

11.5% after eLSH and 15.5% after LSH reported spotting after 1 year. Supracervical hysterectomy significantly improves depressive and anxious symptoms at 3 and at 12 month follow-up for both groups (p < 0.001) independent on residual spotting. Patients with a preoperative continuous bleeding showed a maximum benefit independent on operative method.

CONCLUSION

Laparoscopic supracervical hysterectomy has a positive effect on anxious and depressive symptoms in the short-term and intermediate-term follow-up. The conical excision of the cervical stump reduces postoperative spotting rate, but has no explicit advantage on symptoms of depression or anxiety, irrespective of residual postoperative spotting.

The International Endometriosis Evaluation Program (IEEP Study) - A Systematic Study for Physicians, Researchers and Patients

INTRODUCTION

Endometriosis is a heterogeneous disease characterized by a range of different presentations. It is usually diagnosed when patients present with pain and/or infertility, but it has also been diagnosed in asymptomatic patients. Because of the different diagnostic approaches and diverse therapies, time to diagnosis can vary considerably and the definitive diagnosis may be delayed, with some cases not being diagnosed for several years. Endometriosis patients have many unmet needs. A systematic registration and follow-up of endometriosis patients could be useful to obtain an insight into the course of the disease. The validation of biomarkers could contribute to the development of diagnostic and predictive tests which could help select patients for surgical assessment earlier and offer better predictions about patients who might benefit from medical, surgical or other interventions. The aim is also to obtain a better understanding of the etiology, pathogenesis and progression of the disease.

MATERIAL AND METHODS

To do this, an online multicenter documentation system was introduced to facilitate the establishment of a prospective multicenter case-control study, the IEEP (International Endometriosis Evaluation Program) study. We report here on the first 696 patients with endometriosis included in the program between June 2013 and June 2015.

RESULTS

A documentation system was created, and the structure and course of the study were mapped out with regard to data collection and the collection of biomaterials.

CONCLUSION

The documentation system permits the history and clinical data of patients with endometriosis to be recorded. The IEEP combines this information with biomaterials and uses it for scientific studies. The recorded data can also be used to evaluate clinical quality control measures such as the certification parameters used by the EEL (European Endometriosis League) to assess certified endometriosis centers.

Indications and Route of Hysterectomy for Benign Diseases. Guideline of the DGGG, OEGGG and SGGG (S3 Level, AWMF Registry No. 015/070, April 2015)

Background: Official guideline "indications and methods of hysterectomy" to assign indications for the different methods published and coordinated by the German Society of Gynecology and Obstetrics (DGGG), the Austrian Society of Gynecology and Obstetrics (OEGGG) and the Swiss Society of Gynecology and Obstetrics (SGGG). Besides vaginal and abdominal hysterectomy, three additional techniques have been implemented due to the introduction of laparoscopy. Organ-sparing alternatives were also integrated. Methods: The guideline group consisted of 26 experts from Germany, Austria and Switzerland. Recommendations were developed using a structured consensus process and independent moderation. A systematic literature search and quality appraisal of benefits and harms of the therapeutic alternatives for symptomatic fibroids, dysfunctional bleeding and adenomyosis was done through MEDLINE up to 6/2014 focusing on systematic reviews and meta-analysis. Results: All types of hysterectomy led in studies to high rates of patient satisfaction. If possible, vaginal instead of abdominal hysterectomy should preferably be done. If a vaginal hysterectomy is not feasible, the possibility of a laparoscopic hysterectomy should be considered. An abdominal hysterectomy should only be done with a special indication. Organ-sparing interventions also led to high patient satisfaction rates, but contain the risk of symptom recurrence. Conclusion: As an aim, patients should be enabled to choose that therapeutic intervention for their benign disease of the uterus that convenes best to them and their personal life situation.

No more abdominal hysterectomy for myomata using a new minimally-invasive technique

To perform hysterectomy in uterus myomatosus, there are several surgical techniques. For a uterine weight of >1000 g, after a caesarean section and in nullipara per vaginam, the most common surgical technique for hysterectomy in patients is hysterectomy per laparotomiam. A new endoscopical technique developed to treat such patients and to avoid laparotomy is described in this case report: the laparoscopic combined hysterectomy (LACH) using the change-over technique. Adhesiolysis, preparation of the ureters and the bladder and morcellation of the uterus of 2480 g were performed minimally-invasive in two steps, from one side of the patient with a change-over of the OP-team to the other side of the patient. The cervix was removed per vaginam.

Diagnostic value of palpation and ultrasonography for diagnosing breast cancer recurrence after mastectomy--a comparison

PURPOSE

According to the current interdisciplinary S 3 guideline for breast cancer diagnostics, treatment, and follow-up (1st update 2008), palpation is one of the diagnostic mainstays for follow-up examinations after mastectomy. Although recommended in the manuscript, regular ultrasonographic examinations are neither explicitly mentioned in the statement nor in the follow-up plan. In ambiguous cases, MRI can serve as a supplementary diagnostic method. In order to evaluate the value of palpation and ultrasonography for diagnosing recurrent disease after mastectomy, we analyzed the sensitivity of each method individually and the sensitivity of both methods combined.

MATERIALS AND METHODS

Over a 12-year time span, histological data from 57 patients suspected to have recurrent disease after mastectomy (benign lesions: n = 15, 26.3% malignant lesions: n = 42, 73.7%) were collected. Prior to biopsy, the benign versus malignant character of all lesions was assessed by palpation and ultrasonography (BI-RADS). Sensitivity, specificity, positive predictive value (ppv), negative predictive value (npv), and efficacy were calculated using a contingency table.

RESULTS

Palpation had a sensitivity of 85.7 % and a specificity of 6.7% the respective figures for ultrasonography were 90.5% and 46.7%. The sensitivity of palpation and ultrasonography combined was 100%, i. e. 14.3% higher than the sensitivity of palpation alone. Five cases of recurrent disease which remained undetected by palpation were only recognized by ultrasonography.

CONCLUSION

In agreement with several other studies, the results of our retrospective study show that ultrasonography is superior to palpation for diagnosing recurrent disease after mastectomy. Prospective multicenter studies are needed to evaluate ultrasonographic follow-up before an amendment of the current S 3 guidelines can be recommended with a high degree of evidence.

A safety and efficacy study of a resorbable hydrogel for reduction of post-operative adhesions following myomectomy

BACKGROUND

This multicenter, randomized, single-blind study assessed the safety and efficacy of a resorbable hydrogel ('Hydrogel') for the reduction of post-operative adhesion formation following myomectomy.

METHODS

Women (n = 71) who were undergoing laparoscopic (67.6%) or laparotomic myomectomy were randomized (2:1) to Hydrogel (sprayed over surgically treated areas prior to wound closure, n = 48) or to control (standard care, n = 23). Patients (38 Hydrogel, 20 control) returned 8-10 weeks later for a second look. Adhesions were graded using a modified American Fertility Society (mAFS) scoring method. The primary efficacy measure was the posterior uterus mAFS score.

RESULTS

For Hydrogel and control patients, respectively, mean +/- SD mAFS scores were 0.5 +/- 1.4 and 0.0 +/- 0.0 at baseline, and 1.1 +/- 1.9 and 2.6 +/- 2.2 at the second look. Similarly, mean changes from baseline were 0.8 +/- 2.0 and 2.6 +/- 2.2 (P = 0.01); 95% confidence intervals for these mean changes were (0.16-1.44) and (1.64-3.56). Adverse events were reported by 9.6 and 17.4% of Hydrogel and control patients, respectively. No intra-abdominal infections or post-operative site infections were reported.

CONCLUSIONS

This 71-patient study provides the first clinical evidence of the safety and efficacy of Hydrogel for the reduction of adhesions following myomectomy. The ClinicalTrials.gov Identifier is NCT00562471.

Treatment of a torqued hematosalpinx in the thirteenth week of pregnancy using gasless laparoscopy

Laparotomy and carbon dioxide laparoscopy are relatively traumatic and high-risk operations for patients. They may have negative effects on pregnancy, especially in advanced pregnancy. Gasless laparoscopy was performed on torqued hematosalpinx in a woman in the thirteenth week of pregnancy. After salpingectomy, the pregnancy proceeded normally.

[Minilaparoscopy below the left costal border with radially expanding STEP-Trocar-System in patients with previous pelvic surgery--results of a pilot study]

As a part of a prospective study of 20 patients with previous pelvic surgery, the efficacy of using a 2/3 mm dilatable STEP device (InnerDyne, Inc., Sunnyvale, USA) for the first insertion in the area below the left costal border was tested, using 2 or 3.3 mm minilaparoscopes (Storz). Despite the high incidence of periumbilical omental and bowel adhesions (55%), no complications were observed in any of the 20 patients with previous pelvic surgery. Herewith could be confirmed that the use of a minilaparoscope in the area below the left costal border represents in high risk patients a safe and minimally invasive method for preventing or reducing the number of trocar-related injuries during first trocar insertion. In combination with the use of 2/3 mm disposable STEP-trocars if clinically required an atraumatic dilation and safe insertion of reusable 5 mm, 10 mm or 12 mm trocars is enabled.

Randomized trial comparing a radially expandable needle system with cutting trocars

Sharp trocar insertion for laparoscopic procedures carries with it increased risk for vascular and visceral complications and incisional hernia. In a trial, which randomized 87 patients to treatment with either sharp trocars or a radially expanding needle system with blunt dilator, results showed that with the latter system there was statistically improved patient assessment of pain, a lower complications rate, and shorter procedure time. In the group of patients randomized to treatment with conventional trocars, there were a total of six instrument-related adverse events (6/42): four cases (five incidences) of abdominal wall injuries and one small bowel perforation caused by a Veress needle. Of the 45 patients randomized to the blunt dilator/cannula treatment, there was one adverse event (1/45) that was unrelated to the blunt dilator/cannula system: Veress needle injury to abdominal vasculature. The radially expanding access system demonstrates statistically improved patient postoperative comfort and improved patient safety.

Laparoscopic removal of a 5-cm subserous pedunculated myoma with small instruments

A mobile, subserous, pedunculated myoma was located on the anterior surface of the uterus in a 45-year-old woman. Bipolar coagulation was performed on the pedicle, and the myoma was dissected with an electrical morcellator and removed through the umbilicus. This technique required placement of one 5- to 12-mm cannula in the umbilicus and two 2-mm miniports at the pubic hairline. This technique is easy to perform, and the patient benefits from minimal postoperative pain and excellent cosmetic results.

[Initial experiences and outcome of gasless laparoscopic pelvic lymph node excision combined with Schauta vaginal radical hysterectomy in stage IB cervix carcinoma]

In 11 patients with a cervical cancer stage IB a gasless laparoscopic pelvic lymph node dissection in combination with a vaginal radical Schauta-Amreich-hysterectomy was performed. The technique of the gasless lymph node dissection with the Laparolift (ORIGIN Medsystems, Menlo Park) is described. Because of the advantages of this technique (ability to use conventional and endoscopic instruments, perform irrigation and suction, dot with sponge sticks, change instruments quickly, prepare and remove lymph nodes without influence on visibility) it was possible to obtain a radicality (45 lymph nodes-median value) according to oncological standards for an abdominal radical Wertheim hysterectomy. If the radicality is equivalent to a Wertheim hysterectomy the combination of the radical vaginal Schauta-Amreich-hysterectomy and the gasless laparoscopic pelvic lymph node dissection offers a real alternative to the abdominal Wertheim hysterectomy because of low postoperative morbidity and quick mobilisation.

[During laparoscopy undetected perforation of the small intestine. Modern possibilities for prevention with Visiport and Minioptik]

The postoperative course of a not recognized perforation of the small bowel will be reported. The patient underwent a control-laparoscopy because of ovarian cancer following radical surgery and postoperative chemotherapy. Prevention possibilities with the use of the Minioptik (Storz) and Visiport (Auto Suture) are described.

[Early diagnosis of congenital and acquired intrauterine causes of abortion by post-abortion hysteroscopy]

A prospective study was conducted on the incidence of intrauterine pathology after abortions diagnosed by post-abortion hysteroscopy. In 80 patients outpatient hysteroscopy was performed 8-12 weeks after a dilatation and curettage for incomplete or missed abortions. Intrauterine pathological changes were found in 40 patients. There were 10 cases of uterus subseptus/ bicornis and 7 of uterus arcuatus, 2 submucous myoma and 1 corpus polyp. Intrauterine adhesions were diagnosed in 20 patients. The incidence of intrauterine adhesions was about the same after incomplete abortions and after missed abortions, but in patients with recurrent abortions the incidence was significantly higher than in patients after the first abortion (27.8% versus 14.9%). Post-abortion hysteroscopy is a simple and useful method for early diagnosis of congenital and acquired intrauterine pathology after abortions.

[Hysteroscopic treatment of tubal pregnancy by intratubal injection of methotrexate]

The treatment of 3 non-ruptured tubal pregnancies by hysteroscopic intratubal injection of methotrexate was reported. In all 3 cases the beta-hCG serum levels decreased after injection during clinical, serological and sonographical control. In 2 patients the tubes were patent at a later control. In selected cases the intratubal administration of methotrexate via hysteroscopy is an alternative minimal invasive treatment.

[Hysteroscopy versus hysterosalpingography in diagnosis of sterility and infertility]

In a prospective study of 68 infertile patients the findings of hysterosalpingography and hysteroscopy have been compared. Hysterosalpingography showed in 3 cases false-negative results and in 10 cases false-positive results. Hysterosalpingography is especially limited for diagnostics of intrauterine adhesions. Hysteroscopy should be a necessary component of diagnostics of sterility, also in case of normal hysterosalpingographical findings.

Early pregnancy factor (EPF) as tumour marker in two patients with trophoblastic tumour

Two patients with a trophoblastic tumour (one with an invasive mole and one with a choriocarcinoma) had early pregnancy factor (EPF; detected by rosette inhibition test) in serum. In both cases the EPF already disappeared during surgery which suggests that EPF could be a useful and sensitive tumour marker if laboratory technology for its detection could be improved.