Total laparoscopic radical trachelectomy with intraoperative sentinel node identification for early cervical stump cancer

A 60-year-old patient had undergone a subtotal hysterectomy through a standard laparotomy approach due to multiple uterine myomas 6 years before. She had a 1-month history of postmenopausal uterine bleeding. An endocervical polyp was found and excised. The histopathologic examination showed a poorly differentiated adenocarcinoma. Magnetic resonance imaging of the abdomen and pelvis revealed the mass (4x2x2.5 cm) without parametrial involvement previously identified on vaginal examination. There was no retroperitoneal adenopathy. The patient was successfully treated with total laparoscopic radical trachelectomy in association with laparoscopic intraoperative detection of the sentinel lymph node.

Mutational analysis of amino acid positions crucial for IgE-binding epitopes of the major apple (Malus domestica) allergen, Mal d 1

BACKGROUND

Individual amino acid residues of the major birch pollen allergen, Bet v 1, have been identified to be crucial for IgE recognition. The objective of the present study was to evaluate whether this concept was applicable for the Bet v 1-homologous apple allergen, Mal d 1.

METHODS

A Mal d 1 five-point mutant was produced by PCR techniques, cloned into pMW 172 and expressed in Escherichia coli BL21(DE3) cells. To evaluate the allergenic properties of the engineered protein compared to Mal d 1 wild-type IgE immunoblotting, ELISA, peripheral blood monocytes proliferation assays, and skin prick tests were performed.

RESULTS

The Mal d 1 mutant showed reduced capacity to bind specific IgE as compared to wild-ype Mal d 1 in in vitro assays in the majority of the sera tested. In ELISA, 10 out of 14 serum samples displayed an 88-30% decrease in IgE binding to Mal d 1 mutant compared to wild-type Mal d 1. Skin prick tests in apple-allergic patients (n = 2) confirmed the markedly decreased ability of the Mal d 1 mutant to induce allergic reactions in vivo. However, the relevant T cell epitopes were present in the mutated molecule according to peripheral blood mononuclear cell proliferation assays.

CONCLUSIONS

Our findings suggest that it is possible to modulate the IgE-binding properties of allergens by single amino acid substitutions at crucial positions which might be useful for future immunotherapy of birch-pollen-associated food allergies which are not ameliorated by birch pollen immunotherapy.

New developments in ambulatory hysteroscopic surgery

In the last decade, advancements have been made in hysteroscopic techniques, instrumentation and indications. Vaginoscopic hysteroscopy is performed without medication, cervical dilation and use of vaginal speculum or cervical tenaculum. To prevent complications during uterine access, both misoprostol and laminaria are equally effective for cervical priming. The use of normal saline to distend the uterus prevents hyponatraemia, but hypervolaemia may still be a major problem. Irrigant fluid deficit is best monitored by automated devices. Bipolar electrosurgical systems do not require dispersive return electrodes and do not generate stray currents, thus minimizing the risk of electrical burns. Tissue debulking and extraction are facilitated by vaporizing electrodes or morcellators. Hysteroscopic indications have expanded to include diagnosis and treatment of missed abortion, and cervical and interstitial pregnancies. The most important advancement of hysteroscopy has been proximal tubal access for sterilization.

Hysteroscopic myomectomy in postmenopausal women

STUDY OBJECTIVE

To review the findings in postmenopausal patients undergoing hysteroscopic myomectomy.

DESIGN

Retrospective case-controlled study (Canadian Task Force classification II-2).

SETTING

Private practice.

PATIENTS

Eighteen women with postmenopausal bleeding and two asymptomatic women with abnormal ultrasounds.

INTERVENTIONS

Hysteroscopic myomectomy in 19 patients, with concomitant destruction of the endometrium in 4 patients, and resectoscopic biopsy in 1 patient.

MEASUREMENTS AND MAIN RESULTS

Three patients underwent subsequent gynecologic surgery. One had hysteroscopy to evaluate and remove an asymptomatic residual myoma found on ultrasound. A sarcoma was found in two of the symptomatic patients. Two patients underwent hysterectomy-one for a sarcoma and the other for a carcinoma of the cervix. One patient has had further postmenopausal bleeding.

CONCLUSION

Women who have a submucosal myoma that becomes symptomatic in the menopausal period may be at increased risk for a sarcoma.

Endometrial ablation for heavy menstrual bleeding

PURPOSE OF REVIEW

This review evaluates the currently available evidence regarding resectoscopic endometrial ablation (REA) and the various nonresectoscopic endometrial ablation (NREA) techniques used for heavy menstrual bleeding.

RECENT FINDINGS

Laser endometrial ablation is now used infrequently, largely because of procedure time, but also because of the cost and training associated with the technique. REA can be performed in a wider spectrum of endometrial cavity configurations than NREA and, at least in expert hands, remains the gold standard. Each of the five available types of NREA device possesses advantages and disadvantages over the others with respect to variables such as treatment time, required cervical dilation, and size and configuration of the endometrial cavity. All provide acceptable results that are comparable to that of REA in expert hands. Serious complications seem to be less common with NREA, but uterine perforation and bowel or other visceral injury can still occur. When endometrial-ablation patients were followed for up to 5 years, repeat surgery rates ranged from 20 to 40%, thereby eroding both the direct and indirect treatment-related resource utilization. Levonorgestrel-releasing intrauterine devices demonstrate similar clinical and patient-satisfaction outcomes to endometrial ablation but can be inserted in the office and allow maintenance of fertility.

SUMMARY

Both REA and NREA provide at least short- to intermediate-term options to hysterectomy for patients with heavy menstrual bleeding and normal or near-normal endometrial cavities. Consequently, the ideal candidates are likely those who are within 5 years of menopause.

Laparoscopy versus laparotomy for benign ovarian tumours

BACKGROUND

Over the last ten years laparoscopy has become an increasingly common approach for the surgical removal of benign ovarian tumours. There remains uncertainty as to the value of this intervention. This review has been undertaken to assess the available evidence for the benefits and harms of laparoscopic surgery for benign ovarian tumours compared to laparotomy.

OBJECTIVES

To determine the efficacy, safety and cost of laparoscopic surgery compared with laparotomy in women with ovarian tumours assumed to be benign.

SEARCH STRATEGY

We searched electronic databases, trials registers and reference lists of published trial reports. Review articles were also searched.

SELECTION CRITERIA

All randomised controlled trials comparing laparoscopy versus laparotomy for benign ovarian tumours.

DATA COLLECTION AND ANALYSIS

Three reviewers independently assessed each study's eligibility and quality and extracted data.

MAIN RESULTS

Six randomised controlled trials were identified involving 324 patients. Three subgroups of ovarian tumours were considered: any histological type of benign ovarian tumour, dermoid cysts and endometriomata. Surgical outcomes: The mean duration of surgery was longer in the laparoscopy group compared to the laparotomy group overall (WMD 11.39; 95% CI 0.57 to 22.22). However, heterogeneity was present with substantial inconsistency (I(2)=87%) . The heterogeneity found in these analyses was likely to reflect differences in the patient populations. Adverse effects of surgery: The pooled estimate for febrile morbidity decreased for laparoscopy compared to laparotomy (Peto OR 0.34; 95% CI 0.13 to 0.88). The odds of any adverse effect of surgery (total number of complications - surgical injury and/or post operative complications) were decreased after laparoscopic procedures (Peto OR 0.26; 95% CI 0.12 to 0.55). Short-term recovery: VAS pain scores favoured laparoscopy (WMD -2.36; 95% CI -2.07 to -2.03) andt he odds of being pain free were significantly greater for the laparoscopy group compared to laparotomy (Peto OR 7.35; 95% CI 4.3 to 12.56). Mean length of hospital stay was shorter in the laparoscopy group with reduction 2.79 days (95% CI -2.95 to -2.62) compared to laparotomy. Economic outcomes: There was a significant reduction of US$1045 (95% CI -1361 to -726.97) in the laparoscopy group compared to the laparotomy group in one trial of women with any type of benign ovarian tumour.

AUTHORS' CONCLUSIONS

In women undergoing surgery for benign ovarian tumours, laparoscopy is associated with a reduction in the following; febrile morbidity, urinary tract infection, post operative complications, post operative pain, days in hospital and total cost. These findings should be interpreted with caution as only a small number of studies were identified including a total of only 324 women and not all of the important outcomes were reported in each study.

Laparoscopic hysterectomy: The Kaiser Permanente San Diego experience

STUDY OBJECTIVE

To evaluate patient and surgical characteristics of laparoscopic hysterectomy (LH), including both total laparoscopic hysterectomy (TLH) and laparoscopic supracervical hysterectomy (LSH), compared with total abdominal hysterectomy (TAH).

DESIGN

Retrospective, comparative study (Canadian Task Force classification II-2).

SETTING

Health maintenance organization/residency-training program.

PATIENTS

One hundred eight patients who underwent TLH, 251 patients who underwent LSH, and 255 patients who underwent TAH. There was no randomized controlled system to assign patients to the three types of hysterectomy. Patients with ancillary procedures were excluded from all three groups. The study period included February 2000 through September 2002.

INTERVENTION

Hysterectomy.

MEASUREMENTS AND MAIN RESULTS

Analysis of covariance revealed that laparoscopic procedures require significantly more time to complete than TAH. Adjusted differences were 46.4 minutes longer for TLH (p <.0001) and 38.3 minutes longer for LSH (p <.0001). The adjusted estimated blood loss was 91.0 mL less with TLH (p <.0001) and 72.6 mL less with LSH (p < .0001) than with TAH. The hospital lengths of stay were significantly shorter for LH compared with TAH. The adjusted differences were 41.7 hours less with TLH (p <.0001) and 45.1 hours less with LSH (p <.0001). Rates of major complications were 5.6% with TLH, 0.8% with LSH, and 8.2% with TAH. Rates of minor complications were 17.6% with TLH, 16.7% with LSH, and 14.1% with TAH. Rates of any complication were 21.3% with TLH, 17.1% with LSH, and 20.8% with TAH. (Note: some patients in each group had both a minor and a major complication, so that minor and major complications do not exactly add up to "any complication.") The readmission rates for TLH, LSH, and TAH were 5.6%, 1.2%, and 2.0%, respectively. Same-day discharge for TLH and LSH occurred in 16.7% and 25.1% of patients, respectively. The variables indicating minor complications, any complications, wound infections, urinary tract infections, readmissions, and same-day discharges (in the laparoscopic groups) were not differentiated by surgery type. Major complications were differentiated by procedure class; namely, total hysterectomy (TLH and TAH) had significantly more major complications than LSH (adjusted p = .001). Wound abscesses (16 patients) occurred only in the TAH group (adjusted p <.0001). Pelvic cellulitis (17 patients) occurred in all surgical groups, but was more likely to occur in the LH groups (adjusted p = .01).

CONCLUSIONS

Laparoscopic hysterectomy, both total and supracervical, can be successfully integrated into a large health maintenance organization/residency-training program. Laparoscopic hysterectomy took significantly longer to perform than TAH in this new program. Estimated blood loss was significantly less with LH than with TAH. Hospital length of stay was significantly less with LH than TAH. Major complications with TLH, minor complications with LH, overall complications, wound infections, urinary tract infections, and readmissions appear comparable with these parameters in TAH within the limits of our study size and design. Pelvic cellulitis was significantly more common with LH, and wound abscess was significantly more common with TAH. Major complications were significantly less common with LSH compared with combined TLH and TAH. Same-day discharge after LH seems to be an attractive option worth developing further. Our patients have enthusiastically accepted these new minimally invasive techniques for performing hysterectomy. We anticipate continued expansion of our LH program.

Techniques for the interruption of tubal patency for female sterilisation

BACKGROUND

Female sterilization is the most popular contraceptive method worldwide. Several techniques are described in the literature, however only few of them are commonly used and properly evaluated.

OBJECTIVES

To compare the different tubal occlusion techniques in terms of major and minor morbidity, failure rates (pregnancies), technical failures and difficulties and women's and surgeons' views.

SEARCH STRATEGY

The Cochrane Controlled Trials Register has been searched. A search of the reference lists of identified trials was performed. An additional MEDLINE search was done using an Internet search service Pub Med.

SELECTION CRITERIA

All randomized controlled trials comparing different techniques for tubal sterilization, regardless of the way of entry in the abdominal cavity or the method of anesthesia.

DATA COLLECTION AND ANALYSIS

Trials under consideration were evaluated for methodological quality and appropriateness for inclusion. Nine relevant studies were included and the results were stratified in five groups: tubal ring versus clip, modified Pomeroy versus electrocoagulation, tubal ring versus electrocoagulation, modified Pomeroy versus Filshie clip and Hulka versus Filshie clip. Results are reported as odds ratio for dichotomous outcomes and weighted mean differences for continuous outcomes.

MAIN RESULTS

Tubal ring versus clip: Minor morbidity was higher in the ring group (Peto OR 2.15; 95% CI 1.22, 3.78). Technical difficulties were found less frequent in the clip group ( Peto OR 3.87; 95% CI 1.90, 7.89). There was no difference in failure rates between the two groups (Peto OR 0.70; 95% CI 0.28, 1.76). Pomeroy versus electrocoagulation: Women undergoing modified Pomeroy technique had higher major morbidity than with electrocoagulation technique (Peto OR 2.87; 95% CI 1.13, 7.25). Postoperative pain was more frequent in the Pomeroy group (Peto OR 3.85; 95% CI 2.91, 5.10). Tubal ring versus electrocoagulation: Post operative pain was more frequently reported in the tubal ring group. No pregnancies were reported. Pomeroy versus Filshie clip: In the trial comparing the two interventions only one pregnancy was reported in the Pomeroy group after follow-up for 24 months. No differences were found when comparing Hulka versus Filshie clip in the only study that compared these two devices (Toplis 1988).

REVIEWER'S CONCLUSIONS

Electrocoagulation was associated with less morbidity when compared with tubal ring and other methods. However the risk of burns to the small bowel might be a serious criticism of the approach. The small sample size and the relative short period of follow-up in these studies limited the power to show clinical or statistical differences for rare outcomes such as failure rates. Aspects such as training, costs and maintenance of the equipment may be important factors in deciding which method to choose.

Medication and transference in psychoanalytically oriented psychotherapy of the borderline patient

The regressive potential of the borderline patient has been recognized ever since the term was first introduced by Adolph Stern in 1938. He believed these patients were "too ill for classical psychoanalysis," and indeed almost all who have written on this subject have supported Stern's view, recognizing the severe regressive potential of a borderline patient in unmodified psychoanalysis. Taking medication is not generally considered to be a particularly regressive experience. It should be remembered, however, that for many patients and especially for patients with borderline personality disorder, medication can be both an overvalued hope and a terrifying assault. Thus, although the pharmacologic action of the medication may help to integrate the patient's ego functioning, the very taking of the medication may at the same time initiate subtle and unanticipated regressive drives. Two forces are then set in motion with potentially different effects. In a treatment where the same physician is prescribing medication and doing psychotherapy, the common pathway of these forces is transference. Thus, pharmacologic action may modify transference. And more importantly, because it is less easily recognized, transference issues may affect the patient's subjective experience of the action of the medication. For this reason, it is particularly important that not only diagnostic issues but also transference issues be understood before medication is prescribed.(ABSTRACT TRUNCATED AT 250 WORDS)