Andreas Hackethal

Squamous-cell carcinoma in mature cystic teratoma of the ovary: systematic review and analysis of published data

Up to a quarter of ovarian masses originate from germ cells, and many of these are mature cystic teratomas. The secondary development of malignancy is a rare but well-known phenomenon in patients with ovarian teratomas. Squamous-cell carcinoma accounts for 80% of secondary malignant transformations of ovarian teratomas. We aimed to do an up-to-date systematic review of this rare malignant transformation. 64 suitable studies provided information on 277 patients. Squamous-cell carcinoma in mature cystic teratoma was mainly found in women aged more than 50 years, with high concentrations of squamous-cell-carcinoma antigen and cancer antigen CA125, and with ovarian tumours more than 100 mm in size. Patients with FIGO stage Ia tumours had better survival than those with more advanced disease. Complete resection together with hysterectomy, bilateral salpingo-oophorectomy and lymphadenectomy for patients with advanced disease, followed by adjuvant chemotherapy with an alkylating drug was associated with higher survival, radiotherapy was not. We make proposals for investigation and treatment of this rare disorder.

Intra-abdominal adhesions: definition, origin, significance in surgical practice, and treatment options.

BACKGROUND Intra-abdominal adhesions arise after more than 50% of all abdominal operations and are an important source of postoperative complications. They attach normally separated organs to each other and can cause major problems for the affected patients by giving rise to small bowel obstruction, chronic pelvic pain, dyspareunia, infertility, and higher complication rates in subsequent operations. They are also a frequent source of medicolegal conflict. Thus, every physician should be familiar with their mechanism of origin, their consequences, and the methods by which they can be prevented. METHODS A selective PubMed/Medline search from 1960 onward as well as articles to which these publications referred. The expert consensus position of the European Society for Gynaecological Surgery is also taken into consideration. RESULTS Adhesions arise through aberrant wound healing after peritoneal injury with further influence from a variety of other factors. Preventive measures include minimizing peritoneal injury intraoperatively through the meticulous observance of basic surgical principles, moistening the mesothelium to keep it from drying out, irrigating the peritoneal cavity to remove blood and clot, and keeping the use of intra-abdominal foreign material to a minimum. CONCLUSION Adhesions are an inevitable consequence of intra-abdominal surgery. They can be prevented to some extent with meticulous surgical technique and certain other measures. For operations carrying a high risk of postoperative adhesions, e.g., surgery on the adnexa or bowel, commercially available peritoneal instillates or barrier methods can be used to limit adhesion formation.

A review of the problematic adhesion prophylaxis in gynaecological surgery

BackgroundAdhesions lead to considerable patient morbidity and are a mounting burden on surgeons and the health care system alike. Although adhesion formation is the most frequent complication in abdominal and pelvic surgery, many surgeons are still not aware of the extent of the problem. To provide the best care for their patients, surgeons should consistently inform themselves of anti-adhesion strategies and include these methods in their daily routine.MethodsSearches were conducted in PubMed and The Cochrane Library to identify relevant literature.FindingsVarious complications are associated with adhesion formation, including small bowel obstruction, infertility and chronic pelvic pain. Increasingly, an understanding of adhesion formation as a complex process influenced by many different factors has led to various conceivable anti-adhesion strategies. At present, a number of different anti-adhesion agents are available. Although some agents have proved effective in reducing adhesion formation in randomised controlled trials, none of them can completely prevent adhesion formation.ConclusionTo fulfil our duty to provide best possible care for our patients, it is now time to regard adhesions as the most common complication in surgery. Further research is needed to fully understand adhesion formation and to develop new strategies for adhesion prevention. Large clinical efficacy trials of anti-adhesion agents will make it easier for surgeons to decide which agent to use in daily routine.

Impact of endometriosis on quality of life: A pilot study

Endometriosis affects 6–10% of women in reproductive age, 35–50% of whom experience pain, infertility or both. Mild cases are managed medically but surgery provides relief to women in pain. However, symptoms recur in 75% of cases within 2 years. We investigated the impact of endometriosis on quality of life among 65 women aged 18–60 years working at a city supermarket in Giessen, Germany. Of the 65 women, 12 had undergone surgeries, 22 had dysmenorrhoea, 24 dyspareunia and 3 were infertile. Of the 22 women with dysmenorrhoea, 10 had difficulties performing gardening, housework, sports and leisure activities. Five of these 10 women experienced social isolation, 6 professional setbacks; 6 declined efficiency at work and 3 had taken time off work. Of the 24 women with dyspareunia, 7 experienced minimal, 12 light and 5 moderate to strong pain. Only 16 of these 24 women discussed the problem with their partners. This study demonstrates that pain is a major cause of physical, psycho-social, emotional and professional or work related impairment among women with endometriosis. Because endometriosis is likely to impose emotional and financial burdens, we suggest that future studies should be extended to include interviews with family members.

Effect of Honey on Serum Cholesterol and Lipid Values

Small studies have suggested that honey benefits patients with high cholesterol concentrations. The present study aimed to confirm this finding in a larger group of subjects. Sixty volunteers with high cholesterol, stratified according to gender and hydroxymethylglutaryl-coenzyme A reductase inhibitor (statin) treatment (yes/no), were randomized to receive 75 g of honey solution or a honey-comparable sugar solution once daily over a period of 14 days. Baseline measurements, including body mass index (BMI) and lipid profile, were obtained, and subjects also completed dietary questionnaires and the Inventory for the Assessment of Negative Bodily Affect-Trait form (INKA-h) questionnaire. Measurements were repeated 2 weeks later. BMI and high-density lipoprotein (HDL) cholesterol values were significantly correlated (r = -0.487; P < .001) as were BMI and a lower ratio of low-density lipoprotein (LDL) cholesterol to HDL cholesterol (r = 0.420; P < .001), meaning that subjects with a high BMI had a lower HDL cholesterol value. INKA-h scores and LDL cholesterol values were also significantly correlated (r = 0.273, P = .042). Neither solution influenced significantly cholesterol or triglyceride values in the total group; in women, however, the LDL cholesterol value increased in the sugar solution subgroup but not in the women taking honey. Although ingesting honey did not reduce LDL cholesterol values in general, women may benefit from substituting honey for sugar in their diet. Reducing the BMI lowers the LDL cholesterol value, and psychological interventions also seem important and merit further investigation.

Laparoscopic myomectomy in patients with uterine myomas associated with infertility.

Abstract Although myomectomy is widely accepted in women of childbearing age who wish to retain their fertility, the extent to which myomas affect fertility and whether their removal improves this remain unclear. This study aimed to elucidate the favourable surgical approach in women with uterine myomas and infertility. This retrospective, follow-up study was carried out in three centres in Germany. Data on women who had undergone myomectomy via laparoscopy, laparotomy or conversion to laparotomy in 2000–04 were collected and analysed. Fertility outcome after myomectomy was assessed by follow-up postal questionnaire in a subgroup of women with myoma-associated infertility. Data on 159 women with otherwise unexplained infertility were included (mean age 35 years (range 17–47), mean number of myomas 2.4 (range 1–8) and mean myoma size 6.1 cm (range 0.5–20)). Women who underwent laparoscopy had fewer complications. 39.6% (63/159) of women completed the questionnaire, which showed that the pregnancy rate after myomectomy was 46% in this group. No uterine rupture occurred. Laparoscopy is associated with fewer postoperative complications and since no preoperative or intraoperative factors seem to influence the fertility outcome in women with uterine myomas, it is the treatment of choice in these patients.

Awareness and perception of intra-abdominal adhesions and related consequences: survey of gynaecologists in German hospitals.

OBJECTIVE Intra-abdominal adhesion formation after abdominal surgery is the most common postsurgical complication, and the consequences are a considerable burden for patients, surgeons and health systems. Since a wide variety of factors influence adhesion formation, it is difficult to define clear guidelines on how to reduce adhesion formation in daily practice. Given this dilemma, this study assessed the awareness and perception of adhesion formation among gynaecologists in Germany in order to define a baseline for further research and education. STUDY DESIGN The Clinical Adhesion Research and Evaluation (CARE) group of the University of Giessen designed a questionnaire that was sent to the heads of all gynaecological departments in Germany. The director or one of the surgical consultants was asked to complete the questionnaire and return it for evaluation. RESULTS The completed questionnaire was returned by 279 of 833 gynaecological departments. Interviewed surgeons expected adhesions to form in 15% of cases after laparoscopy and 40% after laparotomy. Before surgery, 83.1% of the respondents told their patients about the risk of prior adhesion formation. More than 60% believed that postsurgical adhesion accounts for major morbidity. Infections within the abdomen, previous surgery and extensive tissue trauma were thought to have the most influence on adhesion formation. Risk of adhesion formation was thought to be highest in endometriosis and adhesiolysis surgery. The respondents agreed on performing adhesiolysis in symptomatic but not in all patients. Only 38.4% used adhesion reduction agents regularly. A total of 65.1% of a repertoire of adhesion prevention agents were familiar to the interviewed surgeons. Only 22.0% of them used anti-adhesion products in clinical practice. In general, the respondents were uncertain whether these products play an important role in adhesion reduction, represented by a range of 1.97+/-0.98% on a scale from 0 to 4. CONCLUSIONS Even though postoperative adhesions are recognized as a major cause for morbidity, and it is widely agreed that infections, extensive tissue trauma and surgery lead to adhesion formation, there is uncertainty about the treatment and prophylactic strategies for dealing with adhesions. This dilemma reflects the awareness and perception of gynaecologists in Germany and is an initial point for further research.

Handheld articulating laparoscopic instruments driven by robotic technology. First clinical experience in gynecological surgery

Kymerax, a new robotic-driven, handheld articulating laparoscopic device, that provides improved triangulation while preserving precise motions, has just recently been introduced to the European market. The KYMERAX System consists of a generator, handles, and interchangeable instruments. We describe a case in which KYMERAX was successfully used during a total laparoscopic hysterectomy. A 42-year-old patient (IIG/IIP) presented with a history of hypermenorrhagia and dysmenorrhagia. Because of a prior cesarean section and to rule out further pathologies possibly associated to dysmenorrhagia, the patient was prepared for a total laparoscopic hysterectomy in our department. The world’s first human use of the KYMERAX System was discussed in details with the patient prior to the procedure. The first clinical use in gynecologic laparoscopy proved to be feasible with the new robotic-driven, articulating, handheld surgical system. KYMERAX may offer benefits in advanced laparoscopy, NOTES, and single-port surgery.

Transvaginal NOTES with semi-rigid and rigid endoscopes that allow adjustable viewing angles

PurposeTo evaluate semi-rigid and rigid endoscopes for transvaginal NOTES surgery.MethodsOne rigid endoscope (EndoCAMeleon, KARL STORZ GmbH & Co. KG, Tuttlingen Germany) and one semi-rigid endoscope (EndoEYE LTF-VH, Olympus Deutschland GmbH, Hamburg, Germany) that allow adjustable viewing angles have been used during four transvaginal gynecological NOTES procedures for chronic pelvic pain and infertility.ResultsFeasibility of transvaginal access to enter the abdominal cavity was shown. Posterior peritoneum, ovaries and tubal patency were evaluated. The evaluated endoscopes did not overcome the inability to explore the anterior pelvic structures.ConclusionsRigid and semi-rigid endoscopes that allow adjustable viewing angles during transvaginal NOTES approaches cannot explore the whole pelvic anatomical structures.

A new variable-view rigid endoscope evaluated in advanced gynecologic laparoscopy: a pilot study.

BackgroundThis pilot study aimed to evaluate the optical performance and clinical handling of a new variable-view rigid endoscope with angulation from 0º to 120º in gynecologic laparoscopic surgery.MethodsThe EndoCAMeleon endoscope was assessed by experienced surgeons and assistants during a variety of advanced gynecologic laparoscopic procedures. After each procedure, both the surgeon and the assistant each completed questionnaires designed to assess the endoscope’s ease of handling and optical performance.ResultsThe endoscope was assessed during 21 advanced procedures. Questionnaire responses confirmed surgeon and assistant satisfaction with the mechanical handling and vision provided by the endoscope. In particular, the ability to vary the viewing angles enabled the surgeon to visualize the surgical site without moving the endoscope shaft.ConclusionsThe new endoscope performed well in the hands of experienced surgeons and assistants undertaking advanced procedures. The variable-view rigid endoscope allows the use of visual ports during primary port entry and enhances vision. Further study is required to evaluate its performance in routine practice.