Effects of preoperative endoanal ultrasound on functional outcome after anal fistula surgery

Objective

Endoanal ultrasound (EAUS) is a recommended preoperative investigation for fistula-in-ano (FiA) which aims to provide the best chance of healing and preservation of continence function. This study aims are (1) to assess effect of EAUS on functional outcome and (2) to determine factors associated with clinical outcomes after FiA surgery.

Design

Retrospective analysis of subjects with cryptogenic FiA between January 2011 and December 2016, in a tertiary hospital, was performed by comparing EAUS and no-EAUS groups. Postoperative change in St. Mark’s faecal incontinence severity score (cFISS=FISS at 6 months after surgery–FISS before surgery) were compared. General linear model was used to determine factors associated with cFISS. Binary logistic regression was used to assess factors related to clinical outcomes. A p-value of <0.05 is considered significant.

Results

We enrolled 339 subjects; 109 (M:F 91:18, mean age 41.7±13.6 years) of 115 in EAUS group and 230 in no-EAUS group (M:F 195:35, mean age 42.6±13.0 years). There were higher proportions of recurrent cases (24.8% vs 13.9%, p=0.014) and complex FiA (80.7% vs 50.4%, p=0.001) in EAUS group. Postoperative FISS (mean±SE) were increased in both groups; preoperative versus postoperative FISS were 0.36±0.20 versus 0.59±0.25 in EAUS group (p=0.056) and 0.31±0.12 versus 0.76±0.17 in no-EAUS group (p<0.001). EAUS had significant effects on cFISS in both univariate analysis, F(1,261)=4.053, p=0.045; and multivariate analysis, F(3,322)=3.147, p=0.025, Wilk’s Lambda 0.972. Other associated factors included recurrent fistula (F(3,322)=0.777, p=0.007, Wilk’s Lambda 0.993) and fistula classification (F(3,322)=16.978, p<0.001, Wilk’s Lambda 0.863). After a mean follow-up of 33.6±28.6 weeks, success rate was 63.3%(EAUS) and 60% (no-EAUS), p=0.822. Factors associated with clinical outcomes were fistula complexity, number of tracts, recurrence, number of previous surgery and type of operations. Accuracy of EAUS was 90.8% and not related to clinical outcomes (p=0.522).

Conclusion

EAUS had favourable effects on functional outcome after FiA surgery while multiple factors were associated with clinical outcomes. EAUS is useful, accurate, inexpensive and can be the first tool for planning of complex and recurrent FiA.

Marsupialization for simple fistula in ano: a randomized controlled trial

BACKGROUND

Marsupialization of anal fistulotomy results in less raw-surface wound and may improve postoperative outcomes. The present study was designed to test the benefit of marsupialization for simple fistula in ano.

MATERIAL AND METHOD

This was a randomized controlled study conducted at King Chulalongkorn Memorial Hospital, Bangkok, Thailand. Fifty patients with simple uncomplicated fistula in ano were allocated into either fistulotomy group or fistulotomy with marsupialization group. Patients with complex fistula in ano, prior incontinence, immuno-compromised status and bleeding tendency were excluded from the present study. The postoperative pain score, the pain score after the first defecation, total amount of the analgesic usage and complications were evaluated. Recurrence was also assessed

RESULTS

There was no difference in the postoperative pain score between the treatment groups. However, there was a significant difference (p = 0.017) in the number of patients who needed pethidine injection (4 patients of the fistulotomy with marsupialization group versus 13 patients of the fistulotomy group). There was no statistical significant difference in the pain score after the first defecation and the amount of paracetamol usage in seven days. Five complications were found only in the fistulotomy group but the significant level was marginal (p = 0.0501). There was no recurrence of thefistula and none of the patients developed anal incontinence after the surgery.

CONCLUSION

Marsupialization for anal fistulotomy is safe. This technique helps to improve the postoperative outcomes.

A novel treatment for haemorrhagic radiation proctitis using colonic irrigation and oral antibiotic administration

AIM

Radiation-induced haemorrhagic proctitis is not uncommon after radiotherapy for pelvic malignancy. Various treatments have been described. Recurrent bleeding and subsequent complications associated with treatment have been reported. Colonic irrigation has been used to treat defaecation disorders; however, it has not been used to treat radiation-induced proctitis.

METHOD

A pilot study was undertaken of 12 patients with haemorrhagic radiation proctitis after radiotherapy. Four patients had had cervical cancer, five had uterine cancer, one had prostatic cancer, one had vesical cancer and one had vaginal cancer. Daily self-administered colonic irrigation with tap water and a 1-week period of oral antibiotics (ciprofloxacin and metronidazole) were prescribed.

RESULTS

The median dose of radiation given was 54 (50-70) Gy. The median interval from radiation to the development of haemorrhagic proctitis was 26 (8-44) months. The median duration of symptomatic rectal haemorrhage prior to treatment was 8 (1-48) months. There was a significant improvement in rectal bleeding after treatment with colonic irrigation and oral antibiotic administration, accompanied by an improvement in bowel frequency and urgency, and diarrhoea. There were no complications. The majority of the patients (11/12) were satisfied with the treatment. The five patients who had previously undergone formalin therapy preferred the treatment regimen used in this study.

CONCLUSION

The preliminary results of colonic irrigation and oral antibiotics indicate that this treatment is safe and effective for radiation-induced proctitis. Further study is warranted.

Internal sphincter myectomy for adult Hirschsprung's disease: a single institute experience

OBJECTIVE

Adult Hirschsprungs disease is a rare disease and frequently misdiagnosed as the long-standing refractory constipation. Almost all cases have short or ultra-short aganglionic segment of distal rectum. The clinical features are different from those in childhood when the diseased segment is long. Amongst the few successful operations that have been used to treat this condition, internal sphincter myectomy has been proposed as a simple and low morbidity procedure, but only a few literatures reported the results. The present study aimed to evaluate the outcomes of anorectal myectomy in adult Hirschsprung's disease.

MATERIAL AND METHOD

All medical records of adult Hirschsprung's disease between January 1, 1997 and April 30, 2008 were retrospectively reviewed The histological criteria for diagnosis were increase in the number of cholinergic nerve fibers in the lamina propria, muscularis mucosae, and submucosa, and the absence of ganglia in the submucosa. All cases underwent internal sphincter myectomy as the first operation. Post-operative complications, number of defecation per week, and the need for a second operation were studied.

RESULTS

Seven patients met the criteria. All patients had the long history of constipation. Anorectal myectomy was performed as the first operation in all cases. Four patients (57%) had good results, without complication and no further operation was needed up to the last follow-up (26-86 months). Two cases underwent subtotal and total colectomy after myectomy to achieve good results eventually. Only one patient had a poor result after Left colectomy and Total proctocolectomy with ileal pouch anal anastomosis.

CONCLUSION

Internal sphincter myectomy, the simple and complication-free procedure, provides the satisfactory outcomes for adult Hirschsprung's disease. This technique should be the first operation for this condition.

A comparison of early postoperative results between urgent closed hemorrhoidectomy for prolapsed thrombosed hemorrhoids and elective closed hemorrhoidectomy

OBJECTIVE

To compare the perioperative complications, analgesics requirement, and length of hospital stay between patients undergoing urgent closed hemorrhoidectomy for prolapsed thrombosed hemorrhoid and elective closed hemorrhoidectomy.

RESEARCH DESIGN

Retrospective, comparative study.

MATERIAL AND METHOD

All records of the patients who underwent urgent and elective hemorrhoidectomy between January 2000 and December 2005 were reviewed. Perioperative complications (bleeding, urinary retention, post-operative thrombosis, and wound dehiscence), analgesic requirement, and length of hospital stay were analyzed.

STATISTICS

Chi-Square Test and Mann-Whitney U Test.

RESULTS

From 1440 patients, 1184 patients met the inclusion criteria. All were done with closed technique. The indication for urgent hemorrhoidectomy was prolapsed thrombosed hemorrhoid in 416 patients (group 1). The indication for elective hemorrhoidectomy were grade 3 and 4 internal hemorrhoid, external hemorrhoid or combined hemorrhoid in 768 patients (group 2). There was no statistically significant difference in urinary retention and bleeding complication between two groups; 31 patients (7.5%) in group 1 and 69 patients (8.9%) in group 2 experienced urinary retention p = 0.426, five patients (1.2%) in group 1 and 10 patients (1.3%) in group 2 had postoperative bleeding, p = 1.000). On the second postoperative week, wound dehiscence was found in nine patients (2.2%) from group 1 and 15 patients (2%) from group 2. On the fourth week, all the wounds were completely healed without granulation or stricture formation. Post-operative meperidine requirement was significantly lower in the urgent hemorrhoidectomy group (0.84 +/- 0.71 vs. 0.99 + 0.81 mg/kg, p < 0.001). Post-operative length of hospital stay were not statistically different (1.017 +/- 0.129 vs. 1.016 +/- 0.124, p = 0.107).

CONCLUSION

Urgent closed hemorrhoidectomy for prolapsed thrombosed hemorrhoids may be a preferable option for patients suffering from this condition.

Sacrectomy for primary sacral tumors

PURPOSE

En bloc resection with adequate margins has provided a chance for cure of primary sacral tumors. However, high sacral lesions are challenging because of the complexity of the surgical approach. The aims of this study were to describe a modification in technique and to evaluate the outcomes.

METHODS

This is a study of eight sacrectomies performed at King Chulalongkorn Memorial Hospital between February 2000 and July 2007. Cadaveric dissections were carried out prior to surgery. We have modified the technique by ligation of the branches of the external iliac veins, resulting in "isolation" of the external iliac veins. Spinopelvic reconstruction was performed for total and extended total sacrectomy. Closure of the sacral defect was done with use of the Hartmann stump and the gluteus maximus flaps.

RESULTS

Two total sacrectomies, one extended total sacrectomy, and five subtotal S1 sacrectomies were performed. En bloc resection with adequate margins was achieved in all patients. The patient who underwent extended total sacrectomy and one patient who underwent total sacrectomy had nonunion requiring removal of the spinopelvic instrumentation. Five patients who underwent subtotal sacrectomy were ambulating well postoperatively, except for one who had an S1 fracture after falling. No sacral hernias were observed. None of the patients developed recurrence of the primary tumor. Mean follow-up time was four years.

CONCLUSIONS

Sacrectomy for primary sacral tumors can be safely conducted, achieving tumor-free margins and acceptable functional and long-term outcomes.

Multimedia article. Laparoscopic restorative proctocolectomy with small McBurney incision for ileal pouch construction without protective ileostomy

PURPOSE

Restorative proctocolectomy is a standard treatment for colorectal diseases over decades. At present, this technique is frequently performed via minimal invasive approach. Most reported techniques of laparoscopic restorative proctocolectomy involved a Pfannenstiel incision for the major part of the operation to be performed openly; a double-stapled pouch anal anastomosis technique and protective ileostomy. This study was designed to demonstrate the modification of this technique.

METHODS

This was a retrospective study of seven patients (4 had ulcerative colitis and 3 had familial adenomatous polyposis) who underwent laparoscopic restorative proctocolectomy at King Chulalongkorn Memorial Hospital between September 2004 and February 2007. The details of the procedure are shown in the video. The techniques involve the following: full mobilization of entire colon and rectum using medial to lateral approach, division of submesenteric arcades for ileal pouch elongation with preservation of three to four inner most arcades of distal ileum segment and preservation of both superior mesenteric and ileocolic trunk, ileal pouch construction via a small (3-4 cm) McBurney incision, transanal mucosectomy with removal of the entire rectum and colon transanally, and handsewn ileal pouch-anal anastomosis. None of the patients underwent protective ileostomy.

RESULTS

Mean surgical time was 360 (270-510) minutes, and median blood loss was 230 (100-400) ml. There were neither conversions nor intraoperative surgical complications. However, one patient developed small-bowel obstruction, which was successfully treated by laparoscopic approach. Anastomotic leakage was not found in this series. All patients have good control of their bowel movement as well as a very good cosmetic result during the follow-up period.

CONCLUSIONS

Laparoscopic restorative proctocolectomy with small McBurney incision for ileal pouch construction, without protective ileostomy, is technically feasible and safe.

New concept of ileocecal junction: Intussusception of the terminal ileum into the cecum

AIM: To prove that the terminal ileum is intussuscepted into the cecum creating the ileocecal junction, contrary to previous valvular concept which has been widely believed.

METHODS: This study is based on gross and microscopic examinations of fresh specimens derived from colonic operations (right hemicolectomy or subtotal colectomy). Data compiled from observing and dissecting of specimens of seven patients are used to examine both gross and microscopic appearance of ileocecal junction.

RESULTS: Intussusception of the terminal ileum was found in every specimen. However, the length of intussusception was different in each specimen.

CONCLUSION: Gross and microscopic appearance studies suggest that the terminal ileum is intussuscepted into the cecum.

Total anal sphincter saving technique for fistula-in-ano; the ligation of intersphincteric fistula tract

OBJECTIVE

To describe a new technique for fistula-in-ano surgery aimed at total sphincter preservation, and evaluate the preliminary results concerning non-healing and intact anal function.

MATERIAL AND METHOD

A prospective observational study in eighteen fistula-in-ano patients treated by ligation of intersphincteric fistula tract (LIFT) technique, from January to June 2006.

RESULTS

Fistula-in-ano in seventeen patients healed primarily (94.4%). There was one non-healing case (5.6%). The mean healing time was four weeks. None had disturbances in clinical anal continence.

CONCLUSION

The early outcome of the LIFT technique is quite impressive. Results warrant a larger study with long-term evaluation. This technique has the potential to become a viable option for fistula-in-ano surgery.

Preoperative capecitabine with pelvic radiotherapy for locally advanced rectal cancer (phase I trial)

OBJECTIVE

Phase I multicenter study defined the maximal tolerated dose (MTD), dose-limiting toxicity (DLT) and safety profile of capecitabine in combination with preoperative radiation for patients with locally advanced rectal cancer (LARC).

MATERIAL AND METHOD

Patients were treated with oral capecitabine (700, 800, 900, 1000, 1100 and 1200 mg/m2 twice daily continuously) plus preoperative whole pelvic irradiation (45-46 Gy in 23-25 fractions over 5-6 weeks). Surgery was performed at the median of 42 days after chemoradiation treatment.

RESULTS

Twenty-seven patients were in this trial. Eighteen patients (3 per dose level) had received capecitabine from 700 mg/m2 twice daily to the highest dose level of 1200 mg/m2 twice daily. There were no grade 3/4 DLTs during dose escalation, a further nine patients were included at the highest capecitabine dose. Two of the twelve patients (16%) receiving capecitabine 1200 mg/m2 twice daily developed grade 3 diarrhea and discontinued treatment. There were no other grade 3/4 adverse events. After capecitabine chemoradiation, 24 of 27 patients (89%) received definite surgery. Primary and lymph node down staging occurred in ten patients (42%). Sphincter-sparing surgery was performed in seven patients (26%) and abdominal-perineal resection was performed in 17 patients (63%).

CONCLUSION

Preoperative capecitabine chemoradiation based on continuous daily capecitabine is very well tolerated in patients with LARC. The authors did not reach the MTD in the present study.

Outcome of familial adenomatous polyposis: a retrospective study

BACKGROUND

Familial adenomatous polyposis (FAP) is characterized by the presence of numerous colorectal adenomatous polyps that progress to colorectal cancer if left untreated. Following colorectal cancer, periampullary cancer and aggressive desmoid tumor are also the common causes of death. The purpose of the present study was to describe the clinical course of FAP patients.

MATERIAL AND METHOD

The authors conducted a retrospective study of 31 FAP patients who were treated at King Chulalongkorn Memorial Hospital (KCMH) between March 2000 and March 2006. Demographic data, family history, symptoms, extracolonic manifestations, operative procedures, pathologic findings, and postoperative results were collected.

RESULTS

Two patients were excludedfrom the present study. The average age of the 29 patients was 33.48 years with the sex ratio (male/female) of 0.93. Seventeen of the 29 patients (58.6%) had a family history of FAP Sixteen of 29 patients were discovered with colorectal cancer with a mean age of34.56 years. Mucous bloody stool was the most common presenting symptom and most of the patients with this symptom (11/13) already had colorectal cancer Gastroduodenal polyps and desmoid tumor were common extracolonic manifestations. The most common operative procedure was restorative proctocolectomy with ileal J pouch (RPC). Wound infection and gut obstruction were the frequent complications. Functional outcomes of patients with RPC were good. The mean age ofpatients with colon cancer was older than the mean age ofpatients without colon cancer However, there was no significant difference between the two groups. The sex ratio and family history of FAP were not statistically different. No significant differences were found in surgical procedures and postoperative complications. On the follow up period, two patients in the later group died of desmoid tumor and pancreatic cancer while seven patients in the former group died of metastatic colon cancer and one with desmoid tumor

CONCLUSION

The proportion ofpatients who were discovered with colorectal cancer in the present study was high with young age onset of cancer Moreover, patients in this group had poorer outcome compared to the group of patients without colorectal cancer; of which, metastatic colorectal cancer was the major cause of death. This result may be due to aggressiveness and advanced stage of disease at the first diagnosis.

Closed vs ligasure hemorrhoidectomy: a prospective, randomized clinical trial

OBJECTIVE

To compare the operative time, postoperative complications, and analgesic requirement between closed hemorrhoidectomy and Ligasure hemorrhoidectomy.

MATERIAL AND METHOD

The study was conducted in a prospectively randomized controlled fashion. Forty-seven patients with grade 3 or 4 hemorrhoids plus external component or skin tag were operated on by either hemorrhoidectomy with Ligasure (24 patients) or closed hemorrhoidectomy (23 patients). One patient in each group was lost to follow up. The operative time, postoperative verbal numeric pain score, analgesic requirement, bleeding, and wound dehiscence between the two groups were compared Unpaired t-tests, Mann-Whitney U tests, or Fisher's Exact tests were used where appropriate.

RESULTS

Demographic and clinical data between two groups were comparable. Operative time for the Ligasure hemorrhoidectomy was significantly shorter than the closed hemorrhoidectomy group (21.70 +/- 11.76 vs 35.68 +/- 14.25 min, p < 0. 001), while the number of resected hemorrhoids in the study group were 2.91 versus 2.18 in the control group. However, there were no differences in post-operative pain score, analgesic requirement, bleeding, or wound dehiscence between the two groups.

CONCLUSION

Ligasure hemorrhoidectomy is superior to closed hemorrhoidectomy in terms of reducing the operative time without affecting postoperative complications.

Minimally invasive surgery training in soft cadaver (MIST-SC)

OBJECTIVES

The purpose of this study was to evaluate the surgical anatomy, tissue plane, organ consistency of soft cadaver and the possibility of minimally invasive surgery training in soft cadaver.

SETTING

Surgical Training Center. Department of Anatomy and Department of Surgery Faculty of Medicine, Chulalongkorn University.

DESIGN

Prospective descriptive study.

MATERIAL AND METHOD

2 soft cadavers were scheduled for fully laparoscopic surgery in upper gastrointestinal, colorectal, hepatopancreatobiliary and solid organs surgery. All the procedures were performed by the experienced surgical staffs and assisted by surgical staffs and/or surgical residents. The surgical anatomy, tissue plane, organ consistency and the satisfactory in performing the procedures were recorded for evaluation.

RESULTS

The surgical anatomy, the tissue consistency the anatomical plane were very well preserved with mean score of 4.72 +/- 0.45. All the surgeons were satisfied with the findings, the mean score was 4.97 +/- 0.18. All the plan procedures were completely performed with great satisfactory results.

CONCLUSION

The Minimally Invasive Surgery Training in Soft Cadaver (MIST-SC) was feasible with great satisfactory. This successful integration of basic and advanced laparoscopic procedures into the soft cadaver setting would be the next step in evolution of MIS training.

Laparoscopic versus open surgery for rectosigmoid and rectal cancer

OBJECTIVES

The aim of this study was to evaluate feasibility and safety of laparoscopic surgery for rectosigmoid cancer and rectal cancer.

MATERIAL AND METHOD

Twenty four patients who underwent laparoscopic surgery for rectosigmoid cancer or rectal cancer were retrospectively evaluated. Results were compared with those of 25 patients who had open surgery at the same period. The procedures of both groups were anterior resection, low anterior resection, coloanal anastomosis, abdominoperineal resection and subtotal colectomy.

RESULTS

The mean operative time was significantly increased in the laparoscopic group. However, this group showed faster recovery of bowel function. There were no differences in the distal margin and yield of harvested lymph nodes of resected specimens. Although anastomotic leakage was comparable between 2 groups, surgical wound infection was significantly higher in open surgery group.

CONCLUSION

Laparoscopic surgery for rectosigmoid cancer and rectal cancer is feasible and can be performed safely with comparable oncological clearance.

Perineum push-up device to facilitate transabdominal suturing of the lower rectum

Pressure on the perineum by the fist facilitates the placement of sutures into the rectal remnant, but put the assisting surgeon on an awkward and strenuous posture. The perineum push-up device to facilitate transabdominal suturing of the lower rectum was invented. The assisting surgeon can push up the perineum more comfortably with his abdominal wall or thigh. The device was tested in fifteen patients. The average distance that can be pushed up is 4.2 cm, which is a significant distance, facilitating in the maneuver of the distal rectal stump.

The new laparoscopic proctocolectomy training (in soft cadaver)

OBJECTIVES

The purpose of the present study was to evaluate the quality of preservation (tissue plane, named vessels identification, consistency of colon and rectum), quality of performing procedures, difficulties and problems and finally the satisfaction of surgeons in laparoscopic proctocolectomy in soft cadaver.

SETTING

Colorectal Division, Department of Surgery and Surgical Training Center Department of Anatomy, Faculty of Medicine, Chulalongkorn University.

DESIGN

Prospective descriptive study

MATERIAL AND METHOD

10 soft cadavers were scheduled for laparoscopic proctocolectomy. The procedures (colon-rectum mobilization and named vessels identification) were performed by 14 experienced surgeons (8 colorectal surgeons) and assisted by surgical residents. The quality of preservation, successfulness and the satisfaction in performing the procedures were recorded using questionnaires for evaluation.

RESULTS

The preservation was very good in every aspect especially tissue plane between colon, mesocolon and retroperitoneum which was clearly dissected, same asfasciapropria of rectum. The named vessels and the tissue consistency were very well preserved and tolerated to laparoscopic equipment handling. The surgeons were satisfied with the tissue handling and dissections. There were two difficulties, the first was air leakage but simply corrected with purse string suture and the second was unflavored smell which was not concerned. Laparoscopic proctocolectomy could be completely performed in soft cadaver.

CONCLUSION

Laparoscopic proctocolectomy could be performed in soft cadavers with great satisfaction. Repeated practice is possible, so the surgeons can gain their experiences outside the operating theatre. This success may shorten the learning curve and may be the new era in cadaver-based training.

Efficacy of metformin on ovulation induction in Asian women with polycystic ovary syndrome

The aim of this study was to assess the efficacy of metformin on induction of ovulation in Asian women with clomiphene citrate (CC)-resistant polycystic ovary syndrome (PCOS). Twenty PCOS women who did not respond to CC were enrolled in the study. All received 500-1500 mg/day of metformin for 4 weeks. If no dominant follicle was observed with monitoring by transvaginal ultrasound, 50-150 mg of CC per day for 5 days were added. Timing of sexual intercourse was determined or intrauterine insemination was carried out 36 h after administration of human chorionic gonadotropin. A total of six cycles, pregnancy or anovulation despite taking 150 mg of CC were considered as completion of the study. Blood samples were obtained before and at the end of the 4th week of treatment for hormonal assay. Ovulation was observed in 68 (89.5%) of 76 cycles, of which 34 (44.7%) occurred with metformin alone. Twelve women conceived; therefore, the pregnancy rate was 17.6% per ovulated cycle and 60% per woman. One (8.3%) had an abortion. Four women had minimal adverse effect, but one experienced a severe gastrointestinal effect during the fourth cycle. Insulin and androstenedione levels were significantly decreased after 4 weeks of treatment. In conclusion, these series demonstrated the excellent efficacy of metformin on induction of ovulation and pregnancy in Asian women with CC-resistant PCOS.

Prevalence of gestational diabetes mellitus and pregnancy outcomes in Asian women with polycystic ovary syndrome

The aim of this study was to determine the prevalence of gestational diabetes mellitus (GDM) and the pregnancy outcomes in Asian women with polycystic ovary syndrome (PCOS). The retrospective cohort study was performed to compare pregnancy outcomes of 47 pregnancies in 41 PCOS women with 264 pregnancies in 222 women with normal menstruation. Logistic regression was used to assess the risk of PCOS on GDM, hypertensive disorder in pregnancy (HDP) and premature delivery. The mean age of both groups was 31 years. The mean body mass index (BMI) and proportion of BMI of > 25 kg/m2 were significantly higher in the PCOS than in the control group. There was no difference in the prevalence of GDM between the PCOS women and the high-risk group of the controls. The prevalence of HDP and premature delivery was significantly greater in PCOS women (21.3 and 13.3%) than in the controls (6.4 and 5.4%), respectively. PCOS was demonstrated as a risk factor for GDM and HDP with borderline statistical significance, but not for premature birth. The Cesarean section rate was higher in the PCOS than in the control group. In conclusion, the prevalence of GDM in Asian women with PCOS is high and comparable to those of a high-risk group.

Surgery of the abdominal aorta: experience of a university hospital in Thailand

One hundred and thirty two patients who underwent aortic surgery at King Chulalongkorn Memorial Hospital, Bangkok, Thailand from January 1991 to December 2000 were studied. Twenty three patients (17.4%) were aged less than 60 years, 102 (77.3%) aged 60-80 years, and 7 (5.3%) were older than 80 years. Ninety eight patients (74.2%) underwent elective operations and 34 (25.8%) underwent emergency operations. Elective abdominal aortic aneurysms (AAA) repair was the most common indication for abdominal aortic surgery (56.0%). Eighteen patients (13.6%) underwent surgery for infected AAA. The incidence of infected AAA was 16.1 per cent among patients with AAA. Fifteen patients (11.4%) had ruptured AAA and 19 patients (14.4%) had aortoiliac occlusive disease. The overall mortality rate was 15.2 per cent. The mortality of elective aortic surgery was 5.1 per cent and of emergency aortic surgery was 44.1 per cent. The mortality of elective AAA repair was 4 per cent. Multiple system organ failure was the most common cause of death (80%), followed by acute myocardial infarction (10%) and exsanguination (10%). The authors conclude that elective surgery on the abdominal aorta is safe and should be performed when indicated to prevent the development of complications requiring emergency surgery which carries a much higher risk.

Prevalence of type 2 diabetes mellitus and impaired glucose tolerance in Asian women with polycystic ovary syndrome

OBJECTIVES

To determine the prevalence of abnormalities of glucose metabolism in Asian women with polycystic ovary syndrome (PCOS) and to assess the different impacts of the 1985 and 1999 WHO consultations and the ADA criteria for the diagnosis of type 2 diabetes mellitus (DM).

METHODS

Eighty-five women with PCOS were consecutively included in the study at the Reproductive Endocrinology Unit, Department of Ob-Gyn, Ramathibodi Hospital, Mahidol University. All women underwent a standard oral glucose tolerance test (OGTT). Fasting insulin and testosterone levels were also measured.

RESULTS

Seventy-nine women consented to the OGTT. The prevalence of impaired glucose tolerance (IGT) and type 2 DM was 22.8 and 15.2% with the 1985 WHO criteria, and 20.3 and 17.7% according to the 1999 WHO consultation criteria, respectively. The recommendation of the ADA using the fasting glucose levels could only determine a prevalence of 6.3% for type 2 DM. The fasting insulin and testosterone levels were significantly higher in DM than IGT and normal glucose tolerance (NGT) subgroups. The PCOS women with abnormalities of glucose metabolism had a greater body mass index (BMI), higher fasting glucose and 2-h post-load glucose levels than those with NGT. The prevalence of glucose intolerance significantly increased with BMI.

CONCLUSIONS

Similar to other ethnic populations, Asian women with PCOS are at risk of developing IGT and type 2 DM especially if obese. The recommendation of the ADA is not appropriate for the diagnosis of type 2 DM in PCOS women.

Defecography in patients with anorectal disorders: a study in 27 cases

Defecography of twenty-seven cases of anorectal disorders with an age range from 22 to 86 years, were evaluated from June 1989 to February 1999. There were 24 patients with constipation, 2 patients with incomplete defecation and mucous bloody stool in one case. The defecographic results were analyzed regarding the following 1) anorectal angle, defined both at rest and straining 2) abnormalities of the rectal configuration during straining, including rectocele, intussusception, infolding and ulceration. 3) pelvic floor descent. The results showed abnormal anorectal angle 5 cases, rectocele 15 cases, intussusception of the rectal wall 3 cases, infolding 11 cases, ulceration 7 cases and anal canal constriction 1 case. Consequently, the patients with anorectal disorders were found to have a variety of rectal abnormalities in which the defecography would be the imaging tool in demonstrating them.

Buserelin acetate implants in the treatment of pain in endometriosis

OBJECTIVE

To examine the treatment of pain in endometriosis by buserelin acetate implants.

DESIGN

Fourteen patients with laparoscopically confirmed pelvic endometriosis were included in the study. All presented with severe dysmenorrhea with or without deep dyspareunia and pelvic pain. Buserelin acetate 6.6 mg. Implants were injected subcutaneously in the lateral region of the anterior abdominal wall, 3 doses every 8 weeks in group 1 (n=7) and 2 doses every 12 weeks in group 2 (n=7). Bone mineral density (BMD) was measured at the lumbar spine by dual energy X-ray absorptiometry (DEXA) before initiation of treatment and 1 year after. Symptoms, pelvic examination, ultrasonogram and serum estradiol were recorded every 4 weeks until two regular menses were established.

RESULTS

All the painful symptoms were relieved and eventually disappeared in every patient within 4-6 weeks. Mean duration of amenorrhea in group 1 (408.4+/-47.7 days) was significantly longer than group 2 (331.3+/-22.4 days), p < 0.01. Mean duration of first observed side effects was 2.7+/-1.6 weeks. Hot flushes were the most common side effects. Serum estradiol levels were below 15 pg/ml in all patients and there were no significant differences between the two groups during amenorrhea. There was significant bone loss in both groups, 6.49+/-4.90 per cent in group 1 and 7.71+/-5.67 per cent in group 2. However, there were no significant differences between the two groups for lumbar BMD before and after treatment.

CONCLUSION

Buserelin acetate implants are effective in the treatment of pain in endometriosis. These implants should have an important clinical application when chronic treatment is indicated. Further study is needed to design how this preparation should be used to minimize the adverse effects.

Transvaginal ultrasonography combined with pelvic examination in the diagnosis of ovarian endometrioma

The aim of this retrospective study was to evaluate the efficacy of TVS and TVS combined with pelvic examination for the diagnosis of ovarian endometrioma. Three hundred and five ovarian masses of 244 patients with either pre-operative or post-operative diagnosis of ovarian tumor and received TVS between January 1, 1996 and December 31, 1998 were included in the study. Of 305 masses, 221 endometriomas of 164 patients were diagnosed histologically. The efficacy of TVS was 84.9 per cent with a sensitivity of 92.3 per cent and specificity of 70.2 per cent. LR+ and LR- were 3.1 and 0.1 respectively. The combination of TVS and pelvic examination with either positive test had a higher sensitivity (98.8%) but lower specificity (26.6%). This combination dramatically improved NPV (97.5%) and LR- (0.05), whereas, the combination with both positive tests had a sensitivity of 78.1 per cent, and specificity of 81.5 per cent. LR+ and LR- were not different from those using TVS alone. In conclusion, the study has shown the role of TVS in the diagnosis of ovarian endometrioma. The combination of TVS and pelvic examination may be useful in ruling out the disease. However, a further prospective study should be performed to confirm the efficacy of the combination.

Cost-effectiveness of IVF in women 38 years and older

OBJECTIVE

To compare the cost per delivery in women younger than 38 years with women equal to or older than 38 years of age attempting IVF.

METHODS

All couples undergoing IVF treatment between October 1991 and September 1998 were enrolled in this study. A standard protocol of controlled ovarian hyperstimulation was employed throughout the study. Four hundred and seven cases were allocated to two groups - group I composed of patients younger than 38 years of age and group II of patient equal to or older than 38 years of age. The total cost of each successful outcome was the goal of our study.

RESULTS

A total of 407 women underwent 722 stimulated cycles for IVF of which 122 cycles (16.89%) did not proceed to oocyte retrieval. We found statistically significant differences in the cancellation rate, the number of hMG ampoules, the number of oocytes retrieved, the number of oocytes fertilized, the number of embryos transferred, the clinical pregnancy rate, the rate of multiple pregnancy, the delivery per initiated cycle and the cost per delivery between the two groups (P<0.05, significant). The cost per delivery in group II was approximately 3.6 times that of group I.

CONCLUSIONS

Women age 38 years or more have less chance of a successful outcome from IVF treatment. Couples contemplating IVF should be provided with accurate information about prognosis for the pregnancy and the financial costs.

Bone mineral density in primary and secondary amenorrhea

Amenorrhea in young women is one of the best clinical indicators for estrogen deficiency, except in the presence of gynecological structural pathology. This study aimed at investigating bone mineral density (BMD) in patients with primary and secondary amenorrhea. Thirty-six patients were enrolled in the study, seven with primary amenorrhea (mean age 24.3 +/- 4.5 yrs.) and twenty-nine with secondary amenorrhea (mean age 31.1 +/- 6.9 yrs.). Eighteen regularly menstruating women (mean age 31.8 +/- 3.7 yrs.) served as controls. BMD was measured at lumbar spine, femoral neck, Ward's triangle and trochanter.

RESULTS

BMD was significantly decreased in both primary and secondary hypoestrogen amenorrheic patients. Primary amenorrheic patients were more severely affected with a BMD mean Z score below 80 per cent (osteopenia) at all sites measured. The age of primary amenorrheic women also strongly correlated with degree of demineralization. This should emphasize the importance of early diagnosis and treatment of young amenorrheic patients.

Efficacy of laparoscopic ovulation induction in polycystic ovary syndrome

This prospective study was aimed to evaluate the efficacy of laparoscopic ovarian electrocoagulation in women with PCOS. Twenty-three PCOS women who had refractory to clomiphene citrate attending the Reproductive Endocrinology Unit, Ramathibodi Hospital between March 1995 and June 1998 were enrolled in the study. In all patients, electrocoagulation on the ovarian surface of both ovaries was performed through laparoscope under general anesthesia. Two patients were lost to follow-up for unknown reasons. The remaining 21 women had a mean age of 30.3 +/- 3.9 years (range 21-39) and mean duration of infertility of 4.1 +/- 2.8 years (range 1-11). There was no intra-operative and post-operative complication. After surgery, ovulation was documented in 16 out of 18 (88.9%) patients. Fifteen (71.4%) patients became pregnant. Fourteen pregnancies (93.3%) occurred within 9 months after surgery. Twelve women (80%) became pregnant in spontaneous cycles without any treatment. The outcomes of pregnancies were 10 live births, 3 ongoing pregnancies and 2 abortions. This study reveals the high efficacy of ovarian electrocoagulation in infertile women with PCOS. High pregnancy and low abortion rates are convincing. This surgical technique should be the treatment of choice for women with CC-resistant PCOS.

Management of endometrial hyperplasia: a retrospective analysis

OBJECTIVE

To determine the incidence of endometrial hyperplasia and to analyse the management of patients with this disorder.

METHOD

Retrospective descriptive study at the Department of Obstetrics and Gynecology, Ramathibodi Hospital. The medical records of patients with endometrial hyperplasia from 1990 to 1995 were analysed. Descriptive statistic was used.

RESULT

Medical records could be obtained in 87 per cent of cases. Incidence of endometrial hyperplasia was 1 per cent of gynecological out-patients and 11 per cent of uterine curettage. Half of the patients had cystic hyperplasia. Main treatment options of patients with cystic hyperplasia were expectant and progestogen therapy. The major treatments of adenomatous hyperplasia were progestogen and hysterectomy. Most patients with atypical hyperplasia underwent hysterectomy. Most of the patients with expectant or hormonal therapy have recurrence of abnormal uterine bleeding.

CONCLUSION

Endometrial hyperplasia is not uncommon in gynecological practice. All gynecologists should be familiar with the pathophysiology and the natural history of this disorder. The unopposed estrogen stimulation should be investigated and corrected. Treatment options should be tailored to individuals according to disease grading, age of the patient and desire of pregnancy. Long-term follow-up until menopause is mandatory to prevent the excessive uterine blood loss and the progression to carcinoma.

Female genital tuberculosis: clinical features and trend

A retrospective study of genital tuberculosis in women attending the Department of Obstetrics and Gynecology between January 1986 and December 1997 revealed 11 patients with a mean age of 38 years (range 23-77). Two patients had genital tuberculosis and tuberculous peritonitis. The incidence was 0.01 per cent of outpatients and 0.05 per cent of inpatients. Eight cases occurred during the last six years. Although the incidence was quite low, a rising trend was observed. Of the clinical features, infertility was the commonest initial symptom (3 cases). The most common site of infection was the endometrium (5 cases) followed by fallopian tube and ovary (3 cases). Chest X-ray of all patients showed no lung infiltration while AFB staining and PCR for tuberculosis were positive in two out of five and one out of two respectively. Six patients received medical treatment only, and three were treated with antituberculous drugs after surgery; all with good results. Tubal reconstructive surgery was performed in two patients without medical treatment. Gynecologists should be aware of this disease to facilitate early diagnosis and treatment.

Hormonal profiles and prevalence of polycystic ovary syndrome in women with acne

One of the important etiologic factors in acne is an increase in sebaceous gland activity, which is androgen dependent. Acne is a common manifestation of hyperandrogenemia. Therefore, acne may not only cause cosmetic concern but may also be a sign of underlying disease. In females, the most common cause of hyperandrogenemia is polycystic ovary syndrome (PCOS). The purpose of this study was to determine the hormonal profiles of women with acne and the prevalence of PCOS in women attending the dermatological clinic with acne problems. The diagnostic criteria of PCOS were clinical findings of menstrual disturbances and hyperandrogenism (acne, seborrhea, hirsutism), pelvic ultrasound imaging of PCO (multiple subcapsular ovarian cysts 2-8 mm. in diameter, with dense echogenic stroma), and an elevated luteinizing hormone (LH) to follicle stimulating hormone (FSH) ratio. There were 51 women with acne; 20 regularly menstruating volunteers without acne served as a control group. PCOS was found in 19 out of 51 patients with acne (37.3%) and none of the control group. Twenty acne patients had abnormal menstruation (39.2%). Acne cases had higher mean levels of serum total testosterone (T), free T, dehydroepiandrosterone sulfate (DHEAS) and prolactin (PRL). No statistically significant difference was observed for LH, FSH or sex hormone binding globulin (SHBG). Because of this high prevalence of PCOS in women with acne, all women presenting with acne should be asked about their menstrual pattern and examined for other signs of hyperandrogenemia. Hormonal profile determination as well as pelvic ultrasonography for ovarian visualization should be performed to confirm the diagnosis of PCOS in female acne patients who have menstrual disturbances.

Propofol anesthesia for transvaginal ultrasound guided oocyte retrieval

The purposes of this study were to determine the efficacy of propofol anesthesia for oocyte retrieval and its effect on IVF outcomes. The anesthetic records of 339 oocyte retrieval cycles were analysed. The mean of total amount of propofol, duration of anesthesia and oocyte pick up were 197.7 +/- 84.2 mg, 25.2 +/- 8.5 and 19.5 +/- 7.4 minutes, respectively. In all cases propofol induced anesthesia within seconds. Mean recovery time was 32.2 +/- 5.4 minutes. Significant nausea and vomiting occurred in one patient. Mild hypotension was observed in 55 out of 339 cycles (16.2%) which did not correlate to the amount and duration of propofol used. A total of 3,417 oocytes were obtained. Fertilization occurred in 2,431 oocytes (71.1%). Mean cleavage rate was 84.5 per cent of fertilized eggs. Mean number of transferred embryo was 4.4 +/- 2.0. Embryos were transferred in 321 cycles, resulted in 73 pregnancies (21.5% per oocyte pick up and 22.7% per transfer). Neither the dose of propofol or the duration of anesthesia has significant effect on pregnancy rate. Propofol anesthesia was found to be efficacious for oocyte retrieval with a rapid induction and recovery, and minimal side effects. The fertilization and pregnancy rates are comparable to other reports using different anesthetic or analgesic agents. However, to reliably determine if propofol affects the IVF outcome a prospective and randomized trial should be performed.

Long-acting triptorelin for the treatment of endometriosis

OBJECTIVE

To evaluate the efficacy and adverse effects of monthly triptorelin injection for the treatment of endometriosis.

METHODS

A multicenter clinical trial including 45 women with endometriosis, treated with triptorelin 3.75 mg i.m. every 4 weeks in six consecutive doses. The main outcome measures were symptom relief, reduction according to revised American Fertility Society (rAFS) scores, reduction in size of ovarian endometrioma, effects on hormone and lipid profiles, changes in bone mineral density (BMD), adverse effects, and return of menstruation. Data were analyzed using repeated measures analysis of variance and paired t-tests.

RESULTS

Pain-related symptoms decreased in all cases after 8 weeks of treatment. Laparoscopic assessment revealed a reduction in rAFS scores in 21 out of 25 cases (mean pretreatment scores 43.44 +/- 5.75 vs. post-treatment scores 22.30 +/- 3.40, P < 0.001). The size of ovarian endometrioma decreased in eight of nine women but none disappeared. Serum luteinizing hormone, follicle-stimulating hormone and estradiol levels were effectively suppressed during treatment. A slight increase in cholesterol and triglyceride levels was observed but all values were within normal limits. After 24 weeks of treatment there was a slight decrease in BMD of total body, lumbar vertebrae and femoral neck but not radius. The main adverse effects included hot flushes, night sweating, vaginal dryness, headache, dizziness and nausea Menstruation returned 83.76 +/- 2.91 days after the last injection of triptorelin.

CONCLUSION

Long-acting triptorelin is efficacious in the treatment of endometriosis and has tolerable side effects.

Outcome of pregnancy in IVF-ET cycle at Ramathibodi Hospital

As assisted reproductive technology is being developed, in vitro fertilization and embryo transfer (IVF-ET) are the treatments of choice for many infertility problems. The outcome of pregnancies achieved by IVF-ET is different from that of spontaneous pregnancies. In this retrospective study, the outcome of pregnancies from 400 IVF treatment cycles performed from October 1991 to October 1994 were reported. There were 80 pregnancies (20% per oocyte retrieval, 21.9% per embryo transfer) with an increased rate of abortion (30%), multiple pregnancy (20%), ectopic pregnancy (6.25%), heterotopic pregnancy (1.25%), preterm delivery (11.8%), low birth weight (35.8%) and cesarean section (62.7%). This study shows that the complication rate of pregnancies from IVF-ET cycles was higher than that found in spontaneous pregnancies. Some complications such as multiple pregnancies may be prevented by limiting the number of transferred embryos. From this study, all IVF-ET pregnancy should be considered as high risk pregnancies.

Determinants of multiple pregnancies in in vitro fertilization other than number of transferred embryos

The aim of this study is to assess the many different parameters involved in the incidence of multiple pregnancies, such as maternal age, stimulation, endometrium, receptivity and the quality of the transferred embryos. During a 3.5 year period, 86 pregnancies were recorded in our IVF unit. A single gestational sac was identified by early ultrasonography in 67 patients, while in 19 others, multiple sacs were noted. Patient characteristics, treatment cycles and embryology results were similar in the two groups. When the number of transferred embryos was kept similar in both groups, EIR was found to be a valuable prognostic determinant for multiple pregnancies in IVF.

Carcinoma of the rectum. Profiles of intraoperative and early postoperative complications

PURPOSE

The aim of this study was to determine the incidence and risk factors that were significant in contributing the intraoperative and early postoperative complications for operations of carcinoma of the rectum.

METHODS

Between 1984 and 1986 inclusive, 426 patients underwent surgery for primary adenocarcinoma of the rectum. Cases of local excision were excluded. The relationship between each complication and nominal risk factors were studied. The types of surgery included an abdominoperineal resection, low anterior resection, low anterior resection with coloanal anastomosis, anterior resection, colostomy, and Hartmann's procedure.

RESULTS

There were two (0.5 percent) deaths. Intraoperative complications occurred in 34 (8 percent) patients. The most common intraoperative complication was presacral bleeding which occurred in 14 patients. Postoperative complications occurred in 214 (50 percent) patients. The two most common complications were urinary retention and urinary tract infection. Abdominoperineal resection had the highest early postoperative complication rate (59 percent). There were 17 clinical anastomotic leaks (7 percent in 221 patients with unprotected anastomoses). The development of complications reached statistical significance with increasing age (P = 0.003), male sex (P = 0.003), increasing weight (P = 0.006), and types of operative procedure (P = 0.001).

CONCLUSIONS

Operations for carcinoma of the rectum can be performed with low mortality. Although the overall early postoperative complications were high, the majority was not life-threatening and usually resolved with time and proper management.

Chemiluminescence immunoassay versus radioimmunoassay for the measurement of reproductive hormones

OBJECTIVES

To compare the hormonal values determined by chemiluminescence immunoassay (CIA) and radioimmunoassay (RIA).

METHODS

Blood samples, drawn from eight volunteers during one menstrual cycle, were assayed for estradiol, progesterone, luteinizing hormone (LH), follicle stimulating hormone (FSH) and prolactin by CIA and RIA methods. The values obtained from these two assay techniques were compared. Statistical analysis were performed using the t-test, Pearson correlation coefficient and simple linear regression analysis.

RESULTS

CIA yielded lower mean values of LH, FSH, progesterone, but higher mean values of prolactin than RIA. Mean estradiol levels assayed by the two methods were similar. There was a good correlation between the hormonal values performed by the two methods. By calculation, the CIA hormonal value could accurately predict the RIA value by 96.6, 93.9, 89.9 and 66.0% for progesterone, LH, FSH and prolactin, respectively.

CONCLUSIONS

The disparity in the hormonal values obtained from different assay methods warrants clinicians to be aware of their clinical interpretation. Using the same reference range for different assay methods is not appropriate. A comparative study between the new and standard assays is essential.

"Simplified IVF": program for developing countries

The aim of this study is to assess the results of the "Simplified IVF" program at Ramathibodi Hospital. Ramathibodi IVF program has been in operation since October, 1991. Some steps of the conventional IVF procedures have been modified due to the limitation of resources. The embryo laboratory is a simple, clean room situated in a different building from the oocyte recovery room. Short protocol of GnRHa/HMG is used for ovarian stimulation. Monitoring of the follicular development is performed by ultrasound alone with limited number of scans (2-3 times/cycle). Oocyte retrieval is carried out under transvaginal ultrasound guidance and the aspirate transported to the embryo laboratory in a simple insulated box. Luteal phase is supported by giving micronized progesterone. Eighty five couples have undergone 105 ovarian stimulation cycles. OR was done in 100 cycles from 80 couples. Total oocytes collected is 1091. The fertilization rate is 75 per cent. Embryos were transferred in 97 cycles. Clinical pregnancy occurred in 25 cycles. Pregnancy rate per OR and ET is 25 and 25.8 per cent respectively. Nineteen patients have delivered (6 twins, 13 singletons). Simplification of procedures has enabled the IVF service to be available in a center with limited resources without compromising the results. Other advantages are improvement of the patient's convenience, cost savings and less time consumed as well as being less stressful.

Two years' experience of intrauterine insemination for the treatment of infertility

The result of a two year (1990-1991) trial of IUI is presented. Discontinuous Percoll-gradient centrifugation technic was used for motile sperm separation. In 174 couples with 610 treatment cycles, there were 49 clinical pregnancies. The pregnancy per patient was 28 per cent and the pregnancy per cycle was 8 per cent. Cycle fecundity by various factors which possibly influence the outcome were assessed. The success rate appeared to be higher in the young female age group, short duration of infertility, secondary infertility, unexplained infertility, a higher number of motile sperm inseminated and dual insemination in a cycle.

Early experience with gamete intrafallopian transfer at Ramathibodi Hospital

This report summarises the result of the GIFT program at Ramathibodi Hospital during 1990-1991. There were 35 treatment cycles in 34 infertile couples. The age of the females varied from 29 to 41 years. Duration of infertility was 3 to 10 years. GIFT was performed during diagnostic laparoscopy in 26 cycles (78%). Other indications were endometriosis (5 cycles), concurrent with myomectomy (3 cycles) and unexplained infertility (1 cycle). Two cases received CC+HMG for superovulation, the others had GnRHa+HMG. Transvaginal ultrasound guided oocyte pick up yielded 2 to 10 oocytes (mean 5.8 oocytes per cycle). Two to 8 oocytes were transferred. All patients received progesterone or HCG for luteal support. In cases of diagnostic laparoscopy, the findings were normal (10 cases), endometriosis (7 cases), pelvic adhesion (6 cases) and myoma uteri 3 cases). No pregnancy was achieved among 18 GIFT cycles performed in 1990. In 1991, after changing some instruments and methods, there were 5 pregnancies out of 17 GIFT cycles (29%). The factors that influenced the outcome were good selection of instruments and method, maturity of oocytes and semen parameters.

The fate of patients following polypectomy alone for polyps containing invasive carcinoma

Eighty-two patients with colon and rectal polyps containing invasive adenocarcinoma treated by polypectomy alone were studied. Seven of 34 patients (21 percent) with sessile lesions had an adverse outcome, including five local recurrences and two distant metastases. They occurred from 4 to 68 months after the polypectomy. Forty-seven pedunculated polyps with invasion to the head (Level 1) or to the stalk (Level 3) and one polyp to the base of the stalk (Level 4) had no evidence of local recurrence or signs of metastasis. Twenty-eight percent of patients were found to have adenomatous polyps, and 4 percent had malignant polyps during the follow-up examinations (range, 3-119 months; mean, 53 months). The findings suggested that pedunculated polyps with invasion to the head (Level 1), neck (Level 2), or stalk (Level 3) can be safely treated with a complete polypectomy provided that the carcinoma is not undifferentiated. Sessile lesions as well as Level 4 pedunculated lesions should be treated aggressively. If resection is not performed, a long-term follow-up in these patients is essential.

The risk of lymph node metastasis in colorectal polyps with invasive adenocarcinoma

One hundred fifty-one patients with colorectal polyps containing invasive adenocarcinoma treated by resection were studied to determine the incidence of lymph node metastasis and whether lymph node metastasis was related to the depth of invasion. Other variables evaluated included size and configuration of the polyp, grade of adenocarcinoma, presence or absence of lymphovascular invasion, and degree of differentiation. In patients with sessile polyps, the incidence of lymph node metastasis was 10 percent. Eighty percent of these lesions had lymphovascular invasion. For pedunculated polyps, the overall incidence of lymph node metastasis was 6 percent. However, there was no incidence of lymph node metastasis when the depth of invasion was limited to the head, neck, and stalk of the polyp (Levels 1, 2, and 3). Only when the depth of invasion reached to the base of the stalk (Level 4) was the risk of lymph node metastasis high (27 percent). The other risk factors were not associated with lymph node metastasis. We concluded that the most significant risk factor for lymph node metastasis in patients with invasive carcinoma in a polyp was invasion into the submucosa of the bowel wall (Level 4).

The efficacy of lisuride in the treatment of hyperprolactinemic amenorrhea

Thirteen women with hyperprolactinemic amenorrhea were treated with lisuride (Dopergin, Schering AG, Germany). The dosage of lisuride was started with 0.1 mg per day and increased to 0.2 mg per day after one week of treatment. Further increment of the drug depended on clinical and laboratory responses of the patients. One patient dropped out from the study due to marked nausea and dizziness. In ten out of twelve patients serum prolactin decreased to normal. Most patients received lisuride 0.2-0.4 mg per day. Only one got more than 0.4 mg per day. Two patients whose serum prolactin levels did not decrease to normal range had uterine bleeding, quite regularly. Menstrual cycle resumed within 23 to 141 days. All galactorrhea disappeared during treatment. Two of five patients who desired pregnancy became pregnant during the treatment. The course and outcome of pregnancies were normal. Common side effects of lisuride treatment were nausea and dizziness. In conclusion, this study demonstrated that lisuride is another effective prolactin inhibiting agent even at low dose. This drug provides an alternative treatment to bromocriptine.

Treatment of endometriosis with gonadotropin releasing hormone agonist (buserelin)

The results of treatment of endometriosis with intranasal buserelin is convincing. The drug effectively suppresses serum estradiol to the menopausal level. Clinical improvement and regression of endometriotic lesions were observed during treatment. Thus, buserelin offers an alternative medical treatment of endometriosis. Further studies of the effects of GnRH agonist on bone mass are needed.