Daniele Maik Bolla

Laparoscopic Indocyanine Green Sentinel Lymph Node Mapping in Pregnant Cervical Cancer Patients.

We present cases of 2 pregnant patients with early-stage cervical cancer who have undergone indocyanine green (ICG) sentinel lymph node (SLN) mapping followed by laparoscopic SLN biopsy, pelvic lymphadenectomy, and cervical conization. Eight milliliters of ICG were injected in the 4 quadrants of the cervix after having obtained an adequate pneumoperitoneum and having inspected the abdominal cavity. SLNs were identified in both hemipelvises in both patients. In the final pathologic analysis, both SLNs and non-SLNs were negative for metastatic disease. No adverse events from ICG injection were recorded. ICG SLN mapping seems to be feasible in pregnant cervical cancer patients.

Hepatic resection during cytoreductive surgery for primary or recurrent epithelial ovarian cancer

PurposeSurgical cytoreduction remains a cornerstone in the management of patients with advanced and recurrent epithelial ovarian cancer. Parenchymal liver metastases determine stage VI disease and are commonly considered a major limit in the achievement of an optimal cytoreduction. The purpose of this manuscript was to discuss the rationale of liver resection and the morbidity related to this procedure in advanced and recurrent ovarian cancer.MethodsA search of the National Library of Medicine’s MEDLINE/PubMed database until March 2015 was performed using the keywords: “ovarian cancer,” “hepatic,” “liver,” and “metastases.”ResultsIn patients with liver metastases, hepatic resection is associated with a similar prognosis as stage IIIC patients. The length of the disease-free interval between primary diagnosis and occurrence of liver metastases, as well as residual disease after resection, is the most important prognostic factors. In addition, the number of liver lesions, resection margins, and the gynecologic oncology group performance status seem to play also an important role in determining outcome.ConclusionsIn properly selected patients, liver resections at the time of cytoreduction increase rates of optimal cytoreduction and improve survival in advanced-stage and recurrent ovarian cancer patients.

The Efficacy of Fibrin Sealant Patches in Reducing the Incidence of Lymphatic Morbidity After Radical Lymphadenectomy: A Meta-Analysis.

Background Although pivotal in the oncological management of most tumors, radical lymphadenectomy is associated with a significant number of lymphatic complications. The aim of this meta-analysis is to evaluate the efficacy of fibrinogen sealant patches in reducing lymphadenectomy-related postoperative complications. Methods/Materials The electronic databases PubMed, Medline, and Scopus were searched using the terms “lymphadenectomy” or “lymph node dissection” and “TachoSil,” “TachoComb,” or “fibrin sealant patch.” Series evaluating the efficacy of fibrin-thrombin collagen sealant patches were included in the meta-analysis. Results Overall, 26 studies were retrieved through the literature search. Ten studies including 720 patients met selection criteria. The use of fibrin-thrombin sealant patches to the sole scope of reducing lymphadenectomy-related complications significantly reduced the incidence of lymphocele, symptomatic lymphocele, the need of percutaneous drainage procedures, the volume of lymph drained, and the duration of the drainage. No effect on wound and/or lymphocele infection was noted. Conclusions This meta-analysis demonstrates that the use of fibrin-thrombin sealant patches significantly reduces the total volume of lymph drained, the duration of the drainage, the incidence of lymphocele and symptomatic lymphocele, and the need for postoperative percutaneous drainage procedures. Its use does not affect the incidence of wound or lymphocele infections.

Laparoscopic Ultrasound-Guided Repair of Uterine Scar Isthmocele Connected With the Extra-Amniotic Space in Early Pregnancy

We present a video of an ultrasound-guided laparoscopic surgical management of a large uterine scar isthmocele connected with the extra-amniotic space in early pregnancy. A case of a pregnant patient who was diagnosed with a large isthmocele connected with the extra-amniotic space on routine ultrasound at 8 weeks of gestational age is presented. The uterine defect was successfully sutured laparoscopically under ultrasound guidance. The pregnancy continued uneventfully, and a healthy baby was delivered via cesarean section at 38 weeks gestational age.

The sFlt-1:PlGF Ratio in Women with Suspected Preeclampsia.

To the Editor: The article by Zeisler and colleagues (Jan. 7 issue)1 showed that a ratio of soluble fms-like tyrosine kinase 1 (sFlt-1) to placental growth factor (PlGF) of 38 or lower ruled out preeclampsia with a negative predictive value of 99.3% within 1 week in women with clinical suspicion of it. Critical in this study are the inclusion criteria used to define “impending” preeclampsia. In medicine, a definition of suspected preeclampsia is lacking, and the inclusion of patients at low risk may artificially increase the negative predictive value of a test by diluting the weight of false negative events. Only 41.5% of the women in the validation cohort had new-onset hypertension or an exacerbation of preexisting hypertension. Other clinical symptoms considered as inclusion criteria are often described in women with overt preeclampsia and used to define its severity, but in the absence of an elevated blood pressure, they lose their clinical importance. We wonder whether the simple inclusion of blood pressure instead of the angiogenic ratio in the evaluation of symptomatic patients would have yielded the same figure for the negative predictive value.

The CORONIS trial on caesarean section

www.thelancet.com Vol 388 October 1, 2016 1373 made on the impact of the diff erent techniques on these outcomes. Our view is different. Take the example of the uterine incision. Although we can visualise the scar and identify apparent defects, how do we interpret these fi ndings unless we know what features lead to scar rupture? The real outcome of clinical interest is scar rupture. The appearance of the scar is a surrogate that is only useful if we can clearly identify the link between diff erent aspects of the appearance of the scar and the risk of a subsequent rupture. We agree that with so many women in the CORONIS trial having a repeat caesarean section without labour the trial was not powered enough to explore such risk. However, this does not mean that we should rely on the appearance of the scar to make clinical decisions. The same applies to abdominal adhesions. If there are adhesions but these cause no symptoms, what is their signifi cance? How can we justify subjecting women to laparoscopy and laparotomy to investigate the presence of adhesions if the majority of these are irrelevant to the woman’s later health? Andrea Papadia and colleagues quote guidance from the American College of Obstetricians and Gynecologists suggesting that we should perform fewer primary caesarean sections and increase the rate of vaginal birth after previous caesarean section. We strongly agree with these sentiments. In low-income and middle-income countries, the occurrence of caesarean section appears to be increasing. CORONIS has shown a high rate of repeat elective caesarean section in the participating hospitals, which were all large, predominantly teaching hospitals that are unlikely to be representative of all hospitals in these countries. This might also explain the low incidence of complications following caesarean section in these settings. Limiting the use of caesarean section to individuals who need this intervention is important to improve outcomes and number of vaginal operative deliveries, and increasing the number of vaginal births after caesarean section. In the CORONIS trial, the repeat caesarean section rate was 66%, whereas the vaginal operative delivery rate was less than 1%. Additionally, the World Health Report 2010 estimated the global cost of unnecessary caesarean sections to be roughly US

Hypertension in pregnancy.

2·32 billion every year. Reducing the number of caesarean sections through strict indications and through the adherence to ACOG guidelines, rather than saving money on the surgical technique adopted, might be a more effective way to control health-care costs in this setting. We congratulate the authors for the importance of the data presented. Nevertheless, we hope that these results will not be used as further evidence that caesarean section is safe.

WS17‐10Sonographic evaluation of the umbilical cord throughout gestation

Purpose of review Hypertension in pregnancy contributes substantially to perinatal mortality and morbidity of both the mother and her child. High blood pressure is mainly responsible for this adverse outcome, in particular when associated with preeclampsia. Although preeclampsia is nowadays a well-known clinical-obstetrical entity, and screening for this complication has been part of routine care during pregnancy for nearly 100 years, its cause is still enigmatic. Recent findings Profound changes of the demographic development of our society, the worldwide rising prevalence of obesity and metabolic disorders, and progress in reproductive medicine will inevitably modify the prevalence of many medical problems in pregnancy. Complications such as gestational diabetes mellitus, chronic hypertension, and preeclampsia will rise and an interdisciplinary approach is necessary to handle these women during pregnancy and also after delivery. Indeed, it is now well established that these women and their offspring born large or small-for-gestational age are at increased risk for severe cardiovascular and metabolic complications later in life. Summary Knowledge of the pregnancy course is not only important for an obstetrician but also increasingly inevitable for the general practitioner. Recognition, classification, and adequate management of hypertensive pregnancy disorders and associated complications may considerably reduce perinatal death and morbidity.

P105Umbilical vein blood flow changes in normal and growth retarded fetuses

Traditionally, the prenatal assessment of the umbilical cord (UC) is limited to the assessment of the number of vessels and to the evaluation of umbilical artery blood flow parameters. Morphologic aspects of the UC have usually been studied by pathologists and retrospectively correlated with the perinatal outcome. The introduction of more sophisticated imaging techniques have offered the possibility to investigate the UC characteristics during fetal life from early to late gestation. A number of investigations have demonstrated that an altered structure of the UC can be associated with pathologic conditions (i.e. preeclampsia, fetal growth restriction, diabetes, fetal demise). Nomograms of the various UC components have been generated and allow the identification of lean or large umbilical cords, entities frequently associated with fetal growth abnormalities and diabetes, respectively. Of note, lean UC in the second and third trimester differs from normal UC not only from a structural point of view but also in the umbilical vein blood flow characteristics. On the other hand a thin UC in the first trimester seems to be a marker for identifying a subset of fetuses at risk for spontaneous abortion and pre‐eclampsia. A Whartons jelly reduction has also been invoked as a possible cause of fetal death in the presence of single umbilical artery. Prenatal morphometric and morphologic UC characteristics as well as UC arterial and venous blood flow parameters in normal and pathologic conditions will be presented and discussed.

F52Evidence of unidirectional pulsatile flow in the umbilical interarterial anastomosis

Background