A randomised prospective trial of intra-operative oesophageal Doppler-guided fluid administration in major gynaecological surgery

Intra-operative oesophageal Doppler monitor-guided fluid management has been associated with improved postoperative length of hospital stay and morbidity in gastrointestinal and orthopaedic surgery. We designed a randomised controlled trial to test the hypothesis that this approach to intra-operative fluid management in major elective open gynaecological surgery would shorten the length of postoperative stay, defined as time to readiness for hospital discharge. Postoperative morbidity was evaluated as a secondary outcome. The oesophageal Doppler monitor group underwent intra-operative fluid management using an oesophageal Doppler-guided stroke volume optimisation algorithm. Control group (conventional fluid therapy) intra-operative fluid management was based on conventional haemodynamic indices. In a single centre, 102 patients were randomly assigned: 51 to the oesophageal Doppler monitor group (51 analysed) and 51 to the control group (50 analysed). Evaluators who were blinded to patient assignment collected postoperative outcome data. There was no difference in the length of postoperative hospital stay between the groups: median (IQR [range]) number of days until ready for discharge was 6 (5-8 [4-25]) days in the oesophageal Doppler monitor group compared with 7 (5-9 [4-42]) days in the control group, p = 0.5. There was no difference between the groups in postoperative morbidity survey scores on postoperative days 1, 3 or 5. Seven patients in the oesophageal Doppler monitor group and 11 in the control group experienced postoperative complications (p = 0.41). These findings question whether intra-operative oesophageal Doppler-guided fluid therapy is of benefit in patients undergoing open gynaecological surgery.

Opportunistic and interventional salpingectomy in women at risk: a strategy for preventing pelvic serous cancer (PSC)

OBJECTIVE

Salpingectomy is proposed as a prophylactic measure to reduce the incidence of tubo-ovarian/pelvic serous cancers. We surveyed the attitudes of obstetrician/gynecologists to incorporating salpingectomy opportunistically into surgery for benign conditions, and electively for young BRCA mutation carriers.

STUDY DESIGN

A questionnaire, designed to assess current standard clinical practice and willingness to perform salpingectomy for female sterilization at abdominal hysterectomy for benign disease (ABH), vaginal benign hysterectomy (VBH) and electively for women with BRCA mutations who wish to postpone oophorectomy was mailed to obstetrician/gynecologists working in Irish hospitals.

RESULTS

In their current practice of interval female sterilization 96% of gynecologists applied clips at laparoscopy and 4% performed salpingectomy, and 73% were willing to consider salpingectomy. Eighty-one percent were willing to consider salpingectomy for sterilization at cesarean section. Gynecologists performing hysterectomy (without oophorectomy) for benign conditions did salpingectomy in 26% at ABH and 5.4% at VBH, and now 90% would consider salpingectomy at ABH and 66% at VBH. Two-thirds of respondents would consider salpingectomy for women at genetic risk of ovarian cancer who want to postpone oophorectomy.

CONCLUSION

Changing general gynecological practice to include more opportunistic salpingectomy has the potential to reduce the incidence of serous cancers. The majority of gynecologists are willing to incorporate more salpingectomies into their surgical practices and consider elective salpingectomy as an interim measure for women with defined genetic risk of pelvic serous cancer.

Myomectomy: a suturing technique for the open procedure

Uterine fibroids are common among women of reproductive age. In women who have not completed their family, a myomectomy is often suggested to preserve and improve fertility. Here, we would like to describe our technique of myomectomy in an open laparotomy procedure.

Vaginal cytology following primary hysterectomy for cervical cancer: is it useful?

BACKGROUND

Vaginal intraepithelial neoplasia (VAIN) is usually detected in patients with synchronous or antecedent cervical or vulval intraepithelial or invasive cancer. VAIN has the potential to progress to malignancy.

AIMS

To determine the incidence and severity and analyse the management of vaginal dysplasia in patients undergoing primary hysterectomy for cervical cancer.

METHODS

A retrospective study (1984-1998) identified 210 primary invasive cervical cancers. One-hundred and twenty-three patients had a primary hysterectomy.

RESULTS

In follow-up six patients were found to have dyskaryosis in a second vaginal smear. Biopsies in the six patients with colposcopic lesions showed VAIN II (n=2), VAIN III (n=1),VAIN III / possible early invasion (n = 1) and invasive carcinoma (n=2). One patient with recurrent squamous cancer received salvage radiotherapy and one with recurrent adenocarcinoma received high dose progestogens and topical 5-fluorouracil.

CONCLUSION

All patients are disease-free at follow-up.

Effects of prior concentric training on eccentric exercise induced muscle damage

BACKGROUND

Exercise induced muscle damage (EIMD) from strenuous unaccustomed eccentric exercise is well documented. So too is the observation that a prior bout of eccentric exercise reduces the severity of symptoms of EIMD. This has been attributed to an increase in sarcomeres in series. Recent studies have suggested that prior concentric training increases the susceptibility of muscle to EIMD following eccentric exercise. This has been attributed to a reduction of sarcomeres in series, which decreases muscle compliance and changes the length-tension relation of muscle contraction.

OBJECTIVE

To assess the effects of prior concentric training on the severity of EIMD.

METHODS

Four men and four women (mean (SD) age 21.1 (0.8) years) followed a four week concentric training programme. The elbow flexor musculature of the non-dominant arm was trained at 60% of one repetition maximum dynamic concentric strength performance, three times a week, increasing to 70% by week 3. After three days of rest, participants performed 50 maximal isokinetic eccentric contractions on both arms. All participants gave written informed consent before taking part in this study, which was approved by the school ethics committee. Strength, relaxed arm angle (RAA), arm circumference, and soreness on active extension and flexion were recorded immediately before eccentric exercise, one hour after, and at 24 hour intervals for three days. Data were analysed with fully repeated measures analyses of variance.

RESULTS

Strength retention was significantly (p<0.01) greater in the control arm than the trained arm (84.0 (13.7)%, 90.4 (14.7)%, 95.2 (10.5)%, 103.5 (7.6)% v 75.5 (11.3)%, 77.6 (15.3)%, 80.1 (13.9)%, 80.9 (12.5)%) at one, 24, 48, and 72 hours respectively. Similarly, soreness was greater in the trained arm (0.7 (0.6), 3.1 (1.4), 3.0 (1.5), 1.9 (2.3)) than in the untrained arm (0 (0.2), 1.6 (1.3), 1.4 (0.6), 0.6 (0.4)) at one, 24, 48, and 72 hours respectively (p<0.05). Concentric training induced a significant reduction in RAA (165.2 (6.7) degrees v 157.3 (4.9) degrees ) before the eccentric exercise bout (p<0.01). This was further reduced and remained lower in the trained arm at all time points after the eccentric exercise (p<0.01). The arm circumference of the concentrically trained arm was significantly greater than baseline (p<0.05) at 72 hours (30.3 (2.9) v 29.8 (3.3) cm).

CONCLUSIONS

These findings extend the understanding of the effects of prior concentric training in increasing the severity of EIMD to an upper limb exercise model. The inclusion of concentric conditioning in rehabilitation programmes tends to exacerbate the severity of EIMD in subsequent unaccustomed exercise. However, where concentric conditioning is indicated clinically, the net effect of conditioning outcome and EIMD may still confer enhanced strength performance and capability to dynamically stabilise a joint system.

Massive pelvic hemorrhage during gynecologic cancer surgery: "pack and go back"

Over a 13-year period, intraabdominal packing has been used to control massive hemorrhage during surgery for gynecologic malignancy in six patients. Five patients had undergone total pelvic exenteration and one total abdominal hysterectomy with bilateral salpingo-oophorectomy for endometrial cancer. Massive hemorrhage was defined as infusion of more than 10 units of blood and replacement of more than one total blood volume. Tamponade was performed using continuous Kerlex rolls (Kendall Co., Boston, MA) in a bowel bag with directed pressure over the hemorrhaging site with abdominal closure. The packs were removed in 48 to 72 hr in the operating room, transabdominally in five patients and transvaginally in one. One postoperative death occurred within 8 hr of surgery. The packing was ultimately successful in the five remaining patients. In five of six patients, tumors were removed before the packing, whereas in one, the tumor was removed concurrently with the pack. In one patient, immediate repacking was required after pack removal, with ultimate hemostasis. Morbidity included "empty pelvis syndrome" in four patients, neuropathy in three (obturator in 1, sciatic in 2), and small bowel obstruction in one. In patients with severe intraoperative hemorrhage, intraabdominal packing has been successful as a mode of treatment.

Evidence for the validity and utility of the Stages of Exercise Behaviour Change scale in young adults

This study examined the validity and utility of the Stages of Exercise Behaviour Change (SEBC) scale in 244 young British adults. One-way ANOVA revealed significant differences (F > 7.34, P < 0.01) between the Exercise Behaviour Change Categories of Precontemplation/Contemplation (n = 49), Preparation (n = 87) and Action/Maintenance (n = 108) in self-report levels of exercise behaviour. Significant differences (F > 3.14, P < 0.05) were also revealed in exercise self-efficacy, physical self-perception sub-domains and global self-esteem scores. Subsequent step-wise discriminant analyses revealed that discrimination between the Categories of Exercise Behaviour Change was possible on the basis of selected behavioural and psychological parameters (Canonical r = 0.76-0.82, Wilks' lambda = 0.30-0.33, chi 2 = 60.3-94.6, d.f. = 14, P < 0.0001). In both males and females, the most dominant discriminatory variables in the first Function were revealed to be perceived physical conditioning and 'strenuous' exercise behaviour. For males, the second Function comprised exercise self-efficacy and perceived bodily attractiveness, whilst for females it comprised perceived bodily attractiveness, perceived sports competence and perceived physical strength. Subsequent cross-validation analysis, using a randomly selected 40% sub-sample, revealed that 67.8-70.7% of subjects were assigned to the correct Category. These results appear to confirm the concurrent validity of the SEBC scale in terms of self-report of exercise behaviour. Furthermore, the utility of the SEBC scale was demonstrated via the ability to predict membership of specific Categories of Exercise Behaviour Change using a selection of behavioural and psychological parameters.

Ileus following gynecologic surgery: management with water-soluble hyperosmolar radiocontrast material

Postoperative ileus following gynecologic surgery can prolong hospitalization and may predispose patients to mechanical obstruction. Our objective was to study the safety and efficacy of a water-soluble, hyperosmolar, radiocontrast material in the management of postoperative ileus in patients having gynecologic surgery. Of 115 cases, 57 were studied prospectively and received water-soluble radio-opaque contrast material via a nasogastric tube if bowel function had not returned by the third day. Fifty-eight well-matched control cases were managed without this material and received a suppository on the third day. The contrast material was well tolerated. Return of bowel function, day of oral intake, subsequent postoperative recovery, and duration of hospital stay were similar in the two groups. Water-soluble, hyperosmolar, radio-opaque contrast material given on the third postoperative day was safe, but of no apparent clinical benefit in resolving ileus following gynecologic surgery.

Artificial Dura Film for femoral vessel coverage after inguinofemoral lymphadenectomy

Eleven patients undergoing inguinofemoral lymphadenectomy for carcinoma of the vulva had the femoral vessels covered with Dura Film (Codman, Randolph, MA); a total of 21 groins were explored. The Dura Film was sutured to the inguinal ligament, sartorius muscle fascia, and adductor longus fascia. Nine of the 21 groins became infected with 3 of these breaking down; each of these 3 required removal of the Dura Film to achieve satisfactory healing. One patient developed a unilateral inflammatory groin mass requiring surgical removal of the Dura Film. One patient developed a chronic draining sinus that required surgical intervention. Seven groins developed lymphocysts. The morbidity was high with 9 of the 11 patients experiencing complications. Coverage of the femoral vessels with Dura Film after inguinofemoral lymphadenectomy is not an effective alternative to human dura mater or sartorius muscle transplant.

Sarcomas of the female genital tract and pelvic soft tissues. A cluster of 14 cases in one year

We report ten uterine and four extrauterine sarcomas encountered in a twelve month period (1989-90). The seven new cases of uterine sarcomas represent an estimated one third of all cases of malignancy of the corpus uteri, which were diagnosed at the gynaecology departments of St James's and Adelaide hospitals in one year. Overall, the prognosis was poor in the uterine sarcoma group-only one patient in clinically tumour free and five have succumbed to their disease. Delay in diagnosis especially in younger women with fibroid uterus contributed to this outcome.

Surgical management of groin node metastases from nonvulvar gynecologic malignancies

Metastatic disease from nonvulvar gynecologic malignancies involving the groin lymph nodes is uncommon. The purpose of this study is to analyze the morbidity, recurrence-free interval, and survival in this group of surgically managed patients. Twenty patients underwent surgical resection of metastatic disease involving the groin lymph nodes between January 1, 1984 and December 31, 1991. Individual factors which have an impact on morbidity, recurrence, and survival were analyzed. Two patients developed wound infection and 2 had wound breakdown. Both of the patients with postoperative wound infection had clinically fixed nodes. None of the patients developed deep venous thrombosis. Long-term complications included lymphocytes in 2 patients and lymphedema in 4 patients. The median local disease progression-free interval was 10 months, with 5 of 20 patients developing local recurrence. The overall median survival was 11 months, with an adjusted 5-year survival rate of 11.5%. Patients with clinically fixed lymph nodes had a shorter median survival (3.6 months) than those with clinically mobile (median, 22.6 months) nodes (P = 0.0032). Metastatic disease from carcinoma of the ovary, fallopian tube, uterus, and cervix involving the groin lymph nodes can be managed safely and effectively with surgical resection. The acute and long-term morbidity is acceptable. Local control can be achieved in the majority of patients.

Use of local flaps in the preservation of fecal continence following resection of perianal neoplasias

The feasibility of achieving curative resection of perianal pre-invasive and invasive lesions with preservation of fecal continence was studied prospectively. Resection of these lesions involved excision of as much as the anterior third of the external anal sphincter. Twenty-two patients had invasive cancer and nine had extensive carcinoma in situ suspicious for invasive disease on preoperative assessment. Anal reconstruction consisted of plication of the external anal sphincter and plication of the puborectalis muscles. The perianal/perineal defects were closed using bilateral rhomboid flaps in 21 patients, unilateral rhomboid flaps in five patients and local advancement flaps in five patients. Twenty-eight patients were ultimately continent of feces, although two required further surgery for incontinence. Two of the three incontinent patients had fecal incontinence before surgery. Two patients had recurrence of invasive cancer, neither of which was perineal or perianal. Curative surgery of selected perianal lesions with preservation of fecal continence can be achieved with local resection and reconstruction with the use of local full thickness skin flaps.

Endometrial fibrinolytic enzymes in women with normal menstruation and dysfunctional uterine bleeding

OBJECTIVE

To study fibrinolysis in the endometrium in women with normal menstruation and dysfunctional uterine bleeding (DUB).

DESIGN

Tissue plasminogen activator activity (t-PA) and antigen (t-PAAg) and plasminogen activator inhibitor Type 1 antigen (PAI-1) were measured in homogenates of endometrium sampled between 24 and 36 h after the onset of menstruation.

SUBJECTS

Women complaining of menorrhagia who had negative findings at clinical examination and curettage had their menstrual blood loss (MBL) measured from the third cycle after D&C. Those with MBL greater than 80 ml per cycle formed the DUB group.

MEASUREMENTS

Fibrinolytic enzyme antigen levels were measured with ELISAs. Tissue plasminogen activator activity was assayed by measuring the rate of conversion of Glu-plasminogen to plasmin, using a chromogenic plasmin substrate.

CONCLUSIONS

There is a strong positive correlation between endometrial t-PA activity on the second day of menstruation and measured menstrual loss (P < 0.05). Concentrations of endometrial t-PAAg and PAI-1 antigen are higher in women with DUB compared with normal women during menstruation.

Whole blood platelet aggregation in moderate and severe pre-eclampsia

OBJECTIVE

To compare whole blood platelet aggregation in moderate and severe pre-eclampsia with normal pregnancy.

DESIGN

Whole blood platelet aggregation in response to collagen, ADP, PAF, adrenalin and arachidonic acid was measured in the pre-eclampsia group at 36 weeks gestation and at 1, 24 and 48 h and at five days and six weeks post delivery. The normal pregnancy group were studied serially at 12, 20, 28, 32, and 36 weeks gestation and at 1, 24, 48 h and six weeks post delivery.

SETTING

Trinity College Medical School, St James's Hospital, Dublin.

SUBJECTS

Thirty women with diagnosed pre-eclampsia were recruited for the study. Fifteen of these women had severe pre-eclampsia and the remaining 15 had moderate disease. The pre-eclampsia group were compared with 20 healthy primigravid women with uncomplicated pregnancies and deliveries.

RESULTS

In women with severe pre-eclampsia, platelet aggregation in response to collagen, ADP, adrenalin and arachidonic acid was significantly lower at 36 weeks gestation compared with normal pregnancy. Lower levels of collagen induced aggregation were also found at 1 h post delivery when compared with normal pregnancy. Women with moderate pre-eclampsia showed a decreased response to aggregating agents at 36 weeks gestation but this was not significant. ADP, collagen and PAF induced aggregation was higher in women with moderate pre-eclampsia at 36 weeks gestation and during the early puerperium compared with severe pre-eclampsia.

CONCLUSIONS

The clinical signs of pre-eclampsia are accompanied by a reduction in platelet responsiveness, the extent of which is related to the severity of the disease. This suggests that an abnormal platelet activation occurs early in pregnancies destined to be complicated by pre-eclampsia. This activation may be involved in the pathogenesis of pre-eclampsia since its inhibition using low dose aspirin has been shown to modify the disease in high risk pregnancies.

Colostomy closure on a gynecologic oncology service

From 7/1/85 to 6/31/92 25 colostomy closures were performed. Twenty-one of the colostomies were performed in relation to gynecologic cancer and the remaining 4 were performed for benign pelvic disease. Nineteen patients underwent simple closure of a transverse loop colostomy. The other 6 patients had their colostomy closed in association with a laparotomy. There were no intraoperative complications related to the colostomy closure. There was 1 postoperative mortality secondary to adult respiratory distress syndrome following reoperation for stricture in the early postoperative period. Three other patients also experienced significant postoperative complications for an overall complication rate of 16%. These included one subcutaneous wound dehiscence, one subcutaneous wound infection, and one anastomotic stricture. One patient required a second colostomy due to recurrence of an obstruction by ovarian cancer in the rectosigmoid area. From the results of this small study, it would appear that colostomy closure is a reasonable endeavor in a selected group of gynecologic cancer patients.

Cyclical variation in endometrial oestrogen and progesterone receptors in women with normal menstruation and dysfunctional uterine bleeding

The majority of women with dysfunctional uterine bleeding ovulate and have normal cyclical changes in gonadotrophins, oestrogen and progesterone. To investigate whether the hormonal milieu at tissue level is different in these women, we measured the endometrial concentration of oestrogen and progesterone receptors at various stages of the menstrual cycle in women with normal menstrual loss (< or = 80 ml/cycle, n = 40) and dysfunctional uterine bleeding (> 80 ml/cycle, n = 44). Menstrual blood loss was measured using the alkaline haematin method. Receptor levels were measured in nuclear and cytosol extracts of endometrium using solid phase immunoassays, based on monoclonal antibodies against receptor protein, which measure the bound and unbound fractions of the receptors. We found endometrial oestrogen (P < 0.01) and progesterone (P < 0.05) receptor levels were higher in the late secretory phase in women with dysfunctional uterine bleeding compared with women with normal menstrual loss. The receptor levels were the same in both groups at all other stages of the menstrual cycle. There was a strong positive correlation between the level of late secretory endometrial oestrogen receptor and measured menstrual blood loss (r = 0.81, P < 0.01). Increased local oestrogen effect is present in the premenstrual endometrium in dysfunctional uterine bleeding.

Menstrual blood loss measurement with gynaeseal

The diagnosis of menorrhagia is usually based on the subjective complaint of heavy menstrual bleeding, although up to 50% of women describing menorrhagia have measured menstrual loss within normal limits. Treatment is usually started without first establishing an objective diagnosis, because menstrual blood loss measurement is not widely available to clinicians. Current laboratory methods of measuring menstrual loss involve extraction of menses from sanitary wear. Many women find collection of sanitary wear unacceptable and laboratory staff find the menstrual extraction procedure unpleasant and time-consuming. We investigated the use of Gynaeseal, a vaginally placed latex menstrual seal, in women with normal menstrual loss (n = 10) and menorrhagia (n = 12) with regard to its suitability for the measurement of menstrual loss and efficacy as alternative sanitary protection. Twenty-one of the 22 women found the device easy to insert, but 16 found it messy to remove. All of the 6 couples having coitus found the device caused no discomfort. All women with menorrhagia and 4 of 12 women with normal menstrual losses were dissatisfied with the menstrual seal provided by gynaeseal. Gynaeseal does not contain menstrual blood efficiently in women with menorrhagia and is therefore unsuitable for the measurement of menstrual blood loss.

The plasminogen activator urokinase and its inhibitor PAI-2 in endometrial cancer

Invasion and metastasis of malignant cells require the disruption of the extracellular matrix, degradation of basement membranes, and intrusion into connective tissue and vascular and lymphatic spaces. Several studies have indicated a role for urokinase (u-PA) in proteolysis of the extracellular matrix and hence in stromal invasion and metastasis. Many malignant cells are known to secrete u-PA. Plasminogen activator inhibitor-type 2 (PAI-2) is an inhibitor of u-PA and is present in several neoplastic cell lines and malignant ascites. We measured u-PA and PAI-2 antigen in tissue homogenates of normal and malignant endometrium from 21 postmenopausal patients. Enzyme-linked immunoassays which measure the bound and unbound, single-and two-chain form of the activator and bound and unbound form of the inhibitor were used. Urokinase was present in four of seven normal (range, 0.15-0.5; median, 0.15 ng/mg protein) and in significantly higher concentrations in all malignant endometrial homogenates (range, 0.41-9.2; median, 3.4 ng/mg protein), P < 0.001. PAI-2 was detectable in four of seven normal endometrial homogenates at low concentrations (range, 1.1-3.1; median, 1.1 ng/mg protein) and in all malignant tissue homogenates at significantly higher levels (range, 1.6-27.3; median, 4.9 ng/mg protein), P < 0.01. Levels of endometrial PAI-2 were higher in stages IC or greater compared to those in stages IA and 1B cancers (P < 0.05). PAI-2 may be useful as a prognostic marker in endometrial cancer.