Incisional Small-Bowel Strangulation after a Caesarean Section: A Case Report

Background and Objectives: Every surgical procedure has the possible risk of complications, and caesarean sections (CSs) are no exception. As CS rates are increasing worldwide, being familiar with rare but possible complications has become extremely important. Case report: We present a case of 25-year-old nulliparous patient who came to our hospital with twin pregnancy for a scheduled induction of labour. An urgent CS was performed due to labour dystocia. On the second postoperative day, the patient started to complain about pain in the epigastrium, but initially showed no signs of bowel obstruction, passing gas, and stools, and could tolerate oral intake. After a thorough examination, an early postoperative complication-small-bowel strangulation at the incision site-was diagnosed. Small bowels protruded in between sutured rectus abdominis muscle causing a strangulation which led to re-laparotomy. During the surgery, there was no necrosis of intestines, bowel resection was not needed, and abdominal wall repair was performed. After re-laparotomy, the patient recovered with no further complications. Conclusions: Although there are discussions about CS techniques, most guidelines recommend leaving rectus muscle unsutured. This case demonstrates a complication which most likely could have been avoided if the rectus muscle had not been re-approximated.

Impact of Hospital Case Volume on Uterine Sarcoma Prognosis: SARCUT Study Subanalysis

BACKGROUND

High-complexity and low-prevalence procedures benefit from treatment by referral centers. The volume of cases necessary to maintain high training in the treatment of gynecologic sarcoma is currently unknown. This study aimed to determine differences in survival and recurrence as a function of the volume of patients treated per center.

METHODS

The multicentric cross-sectional SARComa of the Uterus (SARCUT) study retrospectively collected cases of uterine sarcomas from 44 centers in Europe from January 2001 to December 2007. The survival of patients treated in high case-volume (HighCV) centers was compared with the survival of patients treated in low case-volume (LowCV) centers.

RESULTS

The study enrolled 966 patients: 753 in the LowCV group and 213 in the HighCV. Overall survival (OS) was 117 months, and cancer-specific survival (CSS) was 126 months. The difference was significant (respectively p = 0.0003 and 0.0004, log rank). After adjustment for other confounding factors, the remaining significant factors were age (hazard ratio [HR], 1.04; 95% confidence interval [CI], 1.03-1.05), histology (HR, 1.19; 95% CI, 1.06-1.34), extrauterine involvement (HR, 1.61; 95% CI, 1.24-2.10) and persistent disease after treatment (HR, 3.22; 95% CI, 2.49-4.18). The cytoreduction performed was significantly associated with the CSS and OS in both groups. The log rank for surgical cytoreduction was a p value lower than 0.0001 for OS, lower than 0.0001 for the LowCV centers, and 0.0032 for the HighCV centers.

CONCLUSIONS

The prognosis for patients with uterine sarcoma is directly related to complete tumor cytoreduction, histologic type, and FIGO stage, with significant differences between low and high case-volume centers. Patients with uterine sarcomas should be centralized in HighCV centers to improve their oncologic outcomes.

Prognostic factors in patients with uterine sarcoma: the SARCUT study

OBJECTIVE

Uterine sarcomas are a rare and heterogeneous group of malignancies that include different histological sub-types. The aim of this study was to identify and evaluate the impact of the different prognostic factors on overall survival and disease-free survival of patients with uterine sarcoma.

METHODS

This international multicenter retrospective study included 683 patients diagnosed with uterine sarcoma at 46 different institutions between January 2001 and December 2007.

RESULTS

The 5-year overall survival for leiomyosarcoma, endometrial stromal sarcoma, undifferentiated sarcoma, and adenosarcoma was 65.3%, 78.3%, 52.4%, and 89.5%, respectively, and the 5-year disease-free survival was 54.3%, 68.1%, 40.3%, and 85.3%, respectively. The 10-year overall survival for leiomyosarcoma, endometrial stromal sarcoma, undifferentiated sarcoma and adenosarcoma was 52.6%, 64.8%, 52.4%, and 79.5%, respectively, and the 10-year disease-free survival was 44.7%, 53.3%, 40.3%, and 77.5%, respectively. The most significant factor associated with overall survival in all types of sarcoma except for adenosarcoma was the presence of residual disease after primary treatment. In adenosarcoma, disease stage at diagnosis was the most important factor (hazard ratio 17.7; 95% CI 2.86 to 109.93).

CONCLUSION

Incomplete cytoreduction, tumor persistence, advanced stage, extra-uterine and tumor margin involvement, and the presence of necrosis were relevant prognostic factors significantly affecting overall survival in uterine sarcoma. The presence of lymph vascular space involvement and administration of adjuvant chemotherapy were significantly associated with a higher risk of relapse.

Laparoscopic sentinel lymph node mapping with indocyanine green in endometrial cancer: surgeon's learning curve (cumulative sum analysis)

OBJECTIVES

To evaluate surgeons' learning curves for laparoscopic sentinel lymph node biopsy in endometrial cancer.

METHODS

A prospective observational study was performed at the Oncogynecology Center, Lithuanian University of Health Sciences Hospital, from March 2018 to October 2022. Participating surgeons had no previous experience of laparoscopic sentinel lymph node biopsy with indocyanine green tracer. Cumulative sum analysis was used to create learning curves for the performance of eight surgeons, based on a specific result over a time period. Two different cumulative sum plots were made for each surgeon: successful bilateral sentinel lymph node mapping and removal of sentinel lymph node specimens containing actual lymphatic tissue.

RESULTS

190 patients were included. The overall rate of sentinel lymph node mapping was 89.5%: successful bilateral mapping was achieved in 134 (70.5%) patients, while in 36 (19%) patients sentinel lymph nodes were mapped unilaterally. The bilateral detection rate significantly improved in later study periods (from 59.3% in the first year to 85.0% in the last year; p=0.03). Analysis of the performance of the surgeons for bilateral sentinel lymph node mapping showed that the cumulative sum plot crossed the H₀ limit line after 13 consecutive successful bilateral sentinel lymph node biopsies, indicating an acceptable level of competence to achieve the bilateral detection rate of at least 75%. This was accomplished by only one surgeon after 30 surgeries. Analysis of the performance of the surgeons for identification and removal of specimens containing histologically confirmed lymphatic tissue showed that the cumulative sum plots crossed the H₀ limit line after six consecutive successful sentinel lymph node removals. This was accomplished by most of the surgeons (5 of 8).

CONCLUSION

At least 30 procedures of indocyanine green traced laparoscopic sentinel lymph node biopsy were needed to reach an acceptable level of competence for a bilateral sentinel lymph node detection rate of at least 75%.

TRIAL REGISTRATION NUMBER

ACTRN12619000979156.

The Feasibility of Sentinel Lymph-Node, Mapped with Indocyanine Green, Biopsy in Endometrial Cancer Patients: A Prospective Study

Background and objectives. Systematic pelvic lymphadenectomy (LND) is an essential part of lymph-node status evaluation in endometrial cancer (EC) patients to tailor the adjuvant treatment. However, it is associated with the post-operative lymphatic complications and does not improve the outcomes of the disease. Indocyanine green (ICG) mapped sentinel lymph-node biopsy (SLB) has recently been introduced into the clinical practice as an alternative for the surgical lymph-node evaluation in EC patients with the potential to decrease LND related complications. The aim of our study was to evaluate the feasibility of ICG mapped SLB in low, intermediate, and high-risk EC patients in a center with no previous experience on endoscopic SLB procedure. Materials and Methods: The prospective study was performed. 170 patients with histologically confirmed EC were included. Sentinel lymph-nodes (SLs) were mapped with ICG dye and removed ahead of the total laparoscopic hysterectomy. Low-risk patients received only SLB, while SLB and LND were performed for intermediate and high-risk patients. Results: The overall detection rate of SLs was 88.8%. Bilateral mapping was achieved in 68.2% of the patients. The overall detection rate for low-risk patients was 93.7%, 85.0% for the intermediate-risk group, and 100% for high-risk patients (p = 0.232). The most common anatomical sites of SLs were the external iliac (45.8% on the right and 46.6% on the left) and obturator regions (20.9% and 25.6%, respectively). Positive lymph-nodes were found in 8 (4.7%) patients. The sensitivity of SLB was 75.0% and negative predictive value (NPV)—97.2%. Conclusions: Even in the center with no previous experience, sentinel lymph-node biopsy using ICG mapping is feasible. However, the favorable outcomes might be associated with the learning process of newly established method.

Prognostic factors in patients with vulvar cancer: the VULCAN study

OBJECTIVE

This study aimed to analyze the prognostic factors for overall and progression-free survival in patients with vulvar cancer.

METHODS

This international, multicenter, retrospective study included 2453 patients diagnosed with vulvar cancer at 100 different institutions. Inclusion criteria were institutional review board approval from each collaborating center, pathologic diagnosis of invasive carcinoma of the vulva, and primary treatment performed at the participating center. Patients with intraepithelial neoplasia or primary treatment at non-participating centers were excluded. Global survival analysis and squamous cell histology subanalysis was performed.

RESULTS

After excluding patients due to incomplete data entry, 1727 patients treated for vulvar cancer between January 2001 and December 2005 were registered for analysis (1535 squamous, 42 melanomas, 38 Paget's disease and 112 other histologic types). Melanomas had the worse prognosis (p=0.02). In squamous vulvar tumors, independent factors for increase in local recurrence of vulvar cancer were: no prior radiotherapy (p<0.001) or chemotherapy (p=0.006), and for distant recurrence were the number of positive inguinal nodes (p=0.025), and not having undergone lymphadenectomy (p=0.03) or radiotherapy (p<0.001), with a HR of 1.1 (95% CI 1.2 to 1.21), 2.9 (95% CI 1.4 to 6.1), and 3.1 (95% CI 1.7 to 5.7), respectively. Number of positive nodes (p=0.008), FIGO stage (p<0.001), adjuvant chemotherapy (p=0.001), tumor resection margins (p=0.045), and stromal invasion >5 mm (p=0.001) were correlated with poor overall survival, and large case volume (≥9 vs <9 cases per year) correlated with more favorable overall survival (p=0.05).

CONCLUSIONS

Advanced patient age, number of positive inguinal lymph nodes, and lack of adjuvant treatment are significantly associated with a higher risk of relapse in patients with squamous cell vulvar cancer. Case volume per treating institution, FIGO stage, and stromal invasion appear to impact overall survival significantly. Future prospective trials are warranted to establish these prognostic factors for vulvar cancer.

Lithuania's experience in reducing caesarean sections among nulliparas

BACKGROUND

To evaluate the role of the TGCS to reduce the caesarean section (CS) rate among nulliparas (Robson groups 1 and 2) and to find out which group of women have reduced the CS rate by using this tool.

METHODS

The Robson classification was introduced in Lithuanian hospitals prospectively classifying all the deliveries in 2012. The CS rate overall and in each Robson group was calculated and the results were discussed. The analysis was repeated in 2014 and the data from the selected hospitals were compared using MS EXCEL and SPSS 23.0.

RESULTS

Nulliparas accounted for 43% (3746/8718) and 44.6% (3585/8046) of all the deliveries in 2012 and 2014 years, respectively. The CS rate among nulliparas decreased from 23.9% (866/3626) in 2012 to 19.0% (665/3502) in 2014 (p < 0.001).The greatest decrease in absolute contribution to the overall CS rate was recorded in groups 1 (p = 0.005) and 2B (p < 0.001). Perinatal mortality was 3.5 in 2012 and 3.1 in 2014 per 1000 deliveries (p = 0.764).

CONCLUSION

The TGCS can work as an audit intervention that could help to reduce the CS rate without a negative impact on perinatal mortality.

Pelvic Floor Muscle Training With Or Without Tibial Nerve Stimulation and Lifestyle Changes Have Comparable Effects on The Overactive Bladder. A Randomized Clinical Trial

PURPOSE

To compare effects of transcutaneous posterior tibial nerve stimulation (TPTNS) and pelvic floor muscle training (PFMT) in women with overactive bladder syndrome (OAB).

MATERIAL AND METHODS

We randomized 67 women ? 18 years with OAB to three parallel groups: group I (n = 22) received life-style recommendations (LSR) only; group II (n = 24) had LSR + PFMT and group III (n = 21) had LSR + PFMT + TPTNS. Urgency, evaluated by a 3-day voiding diary before treatment and six weeks later, was the main outcome measure. The King's College Health Questionnaire was also administered.

RESULTS

Urgency was significantly reduced in all three groups from 5.1 ± 3.7 to 3.8 ± 3.2 episodes/day, P = .016 in group I, from 5.2 ± 3.6 to 3.2 ± 2.9, P = .006 in group II and from 6.8 ± 3.1 to 4.4 ± 3.5 in group III, P = .013. There were no intergroup differences. The questionnaire results improved significantly only in group III as regards general health perception, role limitation, physical and social limitations without intergroup differences. Womenimproved their micturition frequency in two groups from 8.9 ± 3.2 to 7.5 ± 2.3 episodes/per day, P = .025 in group II, and from 8.8 ± 2.3 to 7.4 ± 2.0, P = .001 in group III, but only in group II was a significant reduction of urinary incontinence seen from 3.8 ± 4.6 to 2.9 ± 4.8 episodes/day, P = .045.

CONCLUSION

All three treatments lead to effective short-term reduction of urgency in women with OAB, but longterm efficacy evaluation is required.

Implementation of the Robson classification in clinical practice:Lithuania's experience

Background

To determine the cesarean section (CS) rate in Lithuania, identify the groups of women that influence it using the Robson classification and to determine the impact of implementing the use of the Robson classification on the CS rate.

Methods

The Robson classification was introduced in Lithuanian hospitals prospectively classifying all the deliveries in 2012. The overall CS rate, sizes of the Robson groups of women, CS rate in each group and contribution to the overall CS rate from each group was calculated and the results were discussed. The analysis was repeated in 2014 and the data were compared using MS EXCEL and SPSS 23.0.

Results

Nineteen Lithuanian hospitals participated in the study. They represented 84.1% of the deliveries (23,742 out of 28,230) in 2012 and 88.5% of the deliveries (24,653 out of 27,872) in 2014. The CS rate decreased from 26.9% (6379/23,742) in 2012 to 22.7% (5605/24,653) in 2014 (p < 0.001). The greatest contributions to the overall CS rate were made by groups 1, 2 and 5. The greatest decrease in the CS rate was detected in group 2. The absolute contribution to the overall CS rate decreased from 4.9% to 3.8%.

Conclusion

The Robson classification can work as an audit tool to identify the groups that have the greatest impact on the CS rate. It also helps to develop a strategy focussing on the reduction of the CS rate.

Group B streptococcus and Escherichia coli colonization in pregnant women and neonates in Lithuania

OBJECTIVE

To evaluate the prevalence of maternal and neonatal colonization with group B streptococcus (GBS) and Escherichia coli, and examine GBS serotypes and susceptibility to antibiotics.

METHODS

A prospective cross-sectional study was carried out in Lithuania between October 2006 and June 2007. Lower vaginal/rectal swabs were obtained from pregnant women (n=998) and ear canal/throat swabs were obtained from their newborns (n=827) for culture.

RESULTS

Overall, maternal and neonatal GBS colonization rates were 15.3% and 6.4%, respectively. Serotypes III (34.5%) and Ia (29.7%) were most common. All GBS isolates were susceptible to penicillin and 4.1% were resistant to erythromycin. Overall, maternal and neonatal E. coli colonization rates were 19.9% and 14.4%, respectively. In total, 71.4% of newborns with E. coli colonization were born to E. coli-negative mothers. E. coli was resistant to ampicillin and piperacillin in 25.9% and 16.6% of cases, respectively. The majority of E. coli-colonized newborns were contaminated with maternal fecal, but not vaginal, E. coli strains.

CONCLUSION

Maternal and neonatal GBS colonization rates, serotypes, and susceptibility to antibiotics were comparable to those reported in previous studies. Population-based data regarding early-onset neonatal infection rates will enable the formulation of a prevention program for early-onset GBS disease in Lithuania.

Sublingual compared with vaginal misoprostol for labour induction at term: a randomised controlled trial

OBJECTIVE

To compare the efficacy and safety of 50 microg of sublingual misoprostol with 25 microg of vaginal misoprostol administered for labour induction at term. Design Double-blinded, randomised controlled trial. Setting University Hospital, Kaunas, Lithuania. Sample A total of 140 women at term with indications for labour induction. Methods Women were randomised to receive either 50 microg of sublingual misoprostol with vaginal placebo (n = 70) or sublingual placebo with 25 microg of vaginal misoprostol (n = 70) every 4 hours (maximum six doses). Main outcome measures The number of women delivering vaginally within 24 hours of labour induction. Results Fifty-eight women (83%) in the sublingual misoprostol group and 53 (76%) in the vaginal misoprostol group delivered vaginally within 24 hours [relative risk (RR) 1.1, 95% confidential interval (CI) 0.9-1.3]. However, the induction to vaginal delivery time was significantly shorter in the sublingual group (15.0 +/- 3.7 hours) compared with the vaginal group (16.7 +/- 4.1 hours, P = 0.03). The incidence of tachysystole was more than three-fold higher in the sublingual than in the vaginal group (14 versus 4.3%; RR 3.3, 95% CI 0.9-11.6), but this was not statistically significant. There were no significant differences in the incidence of hypertonus or hyperstimulation syndrome, mode of delivery, interventions for fetal distress or neonatal outcomes between the two groups. Conclusion A 50 microg of sublingual misoprostol 4 hourly for labour induction at term seems to have similar efficacy as 25 microg of vaginal misoprostol. Further studies on safety with larger numbers of women need to be conducted before routine sublingual misoprostol use in this setting.

Vaginal misoprostol for cervical priming before hysteroscopy in perimenopausal and postmenopausal women

OBJECTIVE

To evaluate the effectiveness and possible adverse effects of vaginal misoprostol for cervical priming before hysteroscopy in perimenopausal and postmenopausal women.

METHODS

A total of 105 women scheduled for hysteroscopy were randomly assigned to 2 groups. The study group (n=51) received 400 microg of vaginal misoprostol at least 12 h before the procedure and the control group (n=54) received no cervical priming agent. The primary outcome measure was the number of women who required cervical dilation. Secondary outcomes were cervical width (the largest size of Hegar dilator inserted without resistance) as well as complications and adverse effects.

RESULTS

In the misoprostol group 27 women (52.9%) required cervical dilation vs. 53 (98.1%) in the control group (P<0.0001). The largest size of Hegar dilator inserted without resistance was 7.6+/-1.4 mm in the misoprostol group vs. 5.0+/-1.1 mm in the control group (P<0.0001). A similar effect of misoprostol on cervical dilation was also found in the subgroup of treated postmenopausal women. Only 2 women (3.9%) experienced mild lower abdominal pain after misoprostol application.

CONCLUSION

Vaginal misoprostol applied before hysteroscopy reduced cervical resistance and the need for cervical dilation in perimenopausal and postmenopausal women, with only mild adverse effects.

Oral, vaginal and sublingual misoprostol for induction of labor

OBJECTIVE

To evaluate the effectiveness and safety of different administration routes of misoprostol for induction of labor.

METHOD

PubMed, Cochrane Library and EMBASE searches were carried out using the keywords oral, vaginal, sublingual, buccal, misoprostol, labor induction, identifying randomized case-controlled trials comparing different routes for giving misoprostol to induce labor, published in English between 1994 and 2004.

RESULTS

Seventeen studies (3549 participants) were included. Compared to vaginal administration, oral misoprostol was associated with higher failure rates for achieving vaginal delivery within 24 h (odds ratio (OR) 1.61, 95% confidence interval (CI) 1.23-2.10), higher rates of uterine hyperstimulation without fetal heart rate (FHR) changes (OR 2.21, 95% CI 1.12-4.34) and lower cesarean section rates (OR 0.74, 95% CI 0.56-0.97). A lower dose of oral misoprostol (50 microg) compared to the 25-50 microg administered vaginally was associated with a higher rate of vaginal delivery not being achieved within 24 h (OR 3.60, 95% CI 2.10-6.18), more need for oxytocin augmentation (OR 2.19, 95% CI 1.65-2.92), less uterine hyperstimulation both without FHR changes (OR 0.58, 95% CI 0.42-0.80) and with FHR changes (OR 0.34, 95% CI 0.17-0.67) and fewer cesarean sections (OR 0.69, 95% CI 0.51-0.91). Compared to vaginal administration, buccal misoprostol resulted in a higher rate of failure to achieve vaginal delivery after 24 h, more frequent uterine hyperstimulation and lower rates of cesarean section, but these differences were not significant. When 50 mug of misoprostol used sublingually was compared to oral administration, the sublingual misoprostol was associated with less failure to achieve vaginal delivery after 24 h, less oxytocin augmentation and reduced cesarean section, but none of the differences were statistically significant.

CONCLUSIONS

Vaginal misoprostol appears more effective than the equivalent dosage administered orally. However, the vaginal route appears to be associated with a higher risk of uterine hyperstimulation. Sublingual misoprostol seems an effective route of administration, but a lack of data necessitates more clinical trials to establish the effectiveness and safety of the buccal/sublingual route.