Eric J. Bieber

Anterior Abdominal Wall Adhesions after Laparotomy or Laparoscopy

STUDY OBJECTIVE To determine the frequency of postoperative adhesions to the anterior abdominal wall peritoneum that could affect safe placement of the initial laparoscopic umbilical cannula at subsequent procedures. DESIGN Prospective cohort study. SETTING Reproductive endocrinology and infertility service of a tertiary care referral hospital. PATIENTS Two hundred fifteen women, 124 with prior abdominal surgery and 91 with no prior surgery. INTERVENTIONS Surgical histories were reviewed, abdominal skin scars noted, and extent of anterior abdominal wall adhesions prospectively recorded. Statistical analysis was performed with the chi2 test. MEASUREMENTS AND MAIN RESULTS No anterior abdominal wall adhesions were present in 91 patients with no previous surgery or 45 patients with previous laparoscopy (12 had more than 1 laparoscopy; p <0.001 vs laparotomy). Seventeen (59%) of 29 patients with a midline vertical incision had anterior wall adhesions (p <0.05 vs suprapubic transverse incision). Eleven (28%) of 39 with a suprapubic transverse incision had anterior wall adhesions (p <0.001 vs no surgery or laparoscopy). Ninety-six percent of adhesions involved omentum and 29% included bowel. CONCLUSION Prior laparotomy, whether through a midline vertical or suprapubic transverse incision, significantly increased the frequency of anterior abdominal wall adhesions, and these adhesions may complicate the placement of the laparoscopic cannula through the umbilicus.

Reduction of postoperative adhesions by N,O-carboxymethylchitosan: a pilot study

OBJECTIVE To examine the logistics, safety, and efficacy of N,O-carboxymethylchitosan (NOCC) in reducing adhesions in women. DESIGN Multicenter, prospective, randomized, reviewer-blinded clinical trial. SETTING Gynecologic practices. PATIENT(S) Thirty-four patients were enrolled; 17 in each group were available for the safety analysis and 16 for the efficacy analysis. INTERVENTION(S) Adhesion reduction by administration of NOCC vs. Ringers lactate at the conclusion of the initial surgical procedure, as assessed at second-look laparoscopy. The NOCC was applied as 200 mL of a 1% NOCC gel that was tamped in place, followed by 100 mL of 2% NOCC solution. Efficacy was assessed by covariate analysis. MAIN OUTCOME MEASURE(S) Safety and postoperative adhesion formation. RESULT(S) Groups did not differ in age, ethnicity distribution, height, weight, or body mass index. No deaths or serious adverse events were attributable to NOCC, and no adverse events were definitively or probably related to NOCC administration. Adhesions recurred at 61% of sites in controls and 38% of sites in NOCC recipients. De novo grade 1a and 1b adhesions tended to occur more commonly in controls than NOCC recipients. Adhesion extent and severity at second look were also less in NOCC recipients. CONCLUSION(S) Intraperitoneal use of NOCC gel and solution appears to be safe. Despite the small sample, strong trends were identified for reduction of occurrence, extent, and severity of adhesion recurrence and de novo adhesion formation.

Comparison of a novel norgestimate/ethinyl estradiol oral contraceptive (Ortho Tri-Cyclen Lo) with the oral contraceptive Loestrin Fe 1/20

This multicenter study compared the contraceptive efficacy, cycle control, and safety of a new triphasic norgestimate (180/215/250 microg)/ethinyl estradiol 25 microg regimen (Ortho Tri-Cyclen Lo) (n = 1,723) with that of norethindrone acetate 1 mg/ethinyl estradiol 20 microg (Loestrin Fe 1/20) (n = 1,171). Healthy women were treated for up to 13 cycles. Demographics were similar between regimens. Contraceptive efficacy was comparable for Ortho Tri-Cyclen Lo and Loestrin Fe 1/20. The overall and method failure probabilities of pregnancy through 13 cycles were 1.9% and 1.5%, respectively, with Ortho Tri-Cyclen Lo and 2.6% and 2.4%, respectively, with Loestrin Fe 1/20. Breakthrough bleeding and spotting was reported by a significantly lower percentage of participants in the Ortho Tri-Cyclen Lo group compared with the Loestrin Fe 1/20 group. At representative Cycles 1, 3, 6, 9, and 13, breakthrough bleeding and spotting rates were 16.3, 11.5, 10.3, 7.9, and 7.7%, respectively, in the Ortho Tri-Cyclen Lo group and 34.9, 22.9, 22.2, 15.9, and 13.1%, respectively, in the Loestrin Fe 1/20 group. Compliance and safety data were similar for the two regimens.

Risk of anterior abdominal wall adhesions increases with number and type of previous laparotomy

Adhesions to the anterior abdominal wall after previous midline vertical laparotomy were found in 68% of patients undergoing laparoscopy (Childers et al: Gynecol Oncol 50:221, 1993). We reviewed the prevalence of anterior wall adhesions in patients with previous laparotomy incisions who underwent laparoscopy (>95% of patients) or laparotomy. The prevalence of omental and/or bowel adhesions to the anterior abdominal wall in proximity to the umbilicus were tallied and analyzed by incision site (midline vertical or suprapubic transverse) and number of previous laparotomies (one or more than one). The following table illustrates the number of patients in each category with anterior abdominal wall adhesions. While the prevalence of adhesions is increased with more than one previous laparotomy this did not reach statistical significance (Chi-square test). A midline vertical laparotomy does significantly increase the risk for anterior wall adhesions compared to a transverse incision (p<0.05). However, it should be noted that 28% of patients with a previous suprapubic transverse incision (Pfannenstiel or Maylard) had omental and/or bowel adhesions. In this series, one patient with two previous transverse incisions had an incidental enterotomy. We currently employ the technique of LUQ trocar placement in patients with previous midline and suprapubic transverse incisions.

Phosphatidylinositol-specific phospholipase C isoform expression in pregnant and nonpregnant rat myometrial tissue

OBJECTIVE Activation of the phosphatidylinositol signaling pathway plays a significant role during the intracellular signal transduction events activated during agonist-stimulated phasic myometrial contractions. Phospholipase C is an essential molecular component of this signaling pathway. These studies sought to characterize the expression of phospholipase C isoform messenger ribonucleic acid in both pregnant and nonpregnant rat myometrium. STUDY DESIGN Total cellular ribonucleic acid was isolated from myometrial tissue collected from Sprague-Dawley rats by use of the acidic guanidinium thiocyanate-phenol-chloroform extraction technique. After deoxyribonuclease treatment to ensure removal of genomic deoxyribonucleic acid, as well as resolution on formaldehyde-1% agarose horizontal slab gels to rule out degradation, the ribonucleic acid was used for semiquantitative competitive reverse transcriptase-polymerase chain reaction studies to evaluate the expression of five of the reported phospholipase C isoforms. These studies were performed with isoform-specific 20-mer primers and the inclusion of internal standard heterologous deoxyribonucleic acid sequences designed with ends homologous to the isoform-specific primers. The identity of the polymerase chain reaction products was confirmed with restriction endonuclease digestions and homology analysis of the sequenced polymerase chain reaction product deoxyribonucleic acid. RESULTS These reverse transcriptase-polymerase chain reaction studies have confirmed expression of the phospholipase C-beta1a, phospholipase C-beta3, phospholipase C-gamma1, phospholipase C-beta2, and phospholipase C-delta1 isoforms in rat myometrial tissue. During pregnancy the levels of expression of the phospholipase C-beta3, phospholipase C-gamma1, and phospholipase C-delta1 isoforms were increased compared with the levels of expression in myometrium from nonpregnant rats. In myometrium from both pregnant and nonpregnant animals the phospholipase C-beta1 a isoform was expressed at the highest level, the phospholipase C-beta3, phospholipase C-gamma1, and phospholipase C-gamma2 isoforms at an intermediate level, and the phospholipase C-delta1 isoform was expressed at the lowest levels. CONCLUSIONS These studies have confirmed at the messenger ribonucleic acid level significant expression of several isoforms of phospholipase C in both pregnant and nonpregnant myometrial tissue. These observations provide additional support for the hypothesis that the phosphatidylinositol signaling pathway plays an important role in uterine smooth muscle.

Tissue-specific protein kinase C isoform expression in rat uterine tissue.

Objective: Activation of the phosphatidylinositol signaling pathway plays a key role during the generation of agonist-stimulated phasic myometrial contractions. Protein kinase C (PKC), a component of this signaling pathway, has been previously shown to produce feedback inhibition of agonist-stimulated myometrial contractions. The studies described in this report were performed to survey the tissue-specific expression of several PKC isoforms in the rat uterus. Methods: Uterine tissue was obtained from timed pregnant and normally cycling adult female Sprague-Dawley rats. Immunohistochemical studies were performed using the Vectastian ABC immunostaining technique and PKC isoform-specific polyclonal antibodies. Western blot studies were peformed using myometrial tissue separated into cytosol and membrane fractions by differential centrifugation. Results: These studies confirmed significant expression of the PKC-α, -β2, -δ, -η, and -ζ isoforms in myometrium from pregnant and estrus rats, whereas only trace or no expression of the PKC-β1, -γ, -ε, and -θ isoforms was observed. Expression of the PKC-α, -β2, and -η isoforms decreased modestly during the latter days of gestation; in contrast, PKC-δ and -ζ remained stable during this period. The immunohistochemical studies confirmed expression of the PKC-α, -β2, -δ, -η, and -ζ isoforms in both circular and longitudinal smooth-muscle layers of the near-term pregnant rat uterus. Conclusion: In summary, these studies have confirmed significant levels of expression of several isoforms of PKC in estrus and near-term pregnant rat uterine tissue, which was most prominent in the smooth-muscle cells of the myometrium.

Transvaginal intratubal insemination by tactile sensation: a preliminary report

Transvaginal catheterization of the fallopian tube has gained increased popularity for transfer of embryos and gametes. Forty-five ITIs were performed on 32 patients using the novel approach of tubal transfer via tactile sensation. This group of patients had undergone an average of 5.2 IUIs before ITI. There were a total of 11 pregnancies, 6 occurring with hMG stimulation and 5 with CC-stimulated cycles (34% PR per patient). Three pregnancies ended with spontaneous abortion, and one patient developed acute salpingitis necessitating laparotomy. These data suggest ITI may be effective in assisted reproduction but, as other invasive procedures, is not without risk.

Protease-activated receptor isoform expression in pregnant and nonpregnant rat myometrial tissue.

Objective: Three protease-activated receptor (PAR1, 3, and 4) isoforms have been shown to be responsible for the cellular effects of thrombin; another PAR isoform (PAR2) is responsible for the cellular effects of trypsin. The present studies sought to test the hypothesis that one (or more) of these PAR isoforms is expressed in myometrial tissue, thereby accounting for the uterotonic effects of these novel agonists. Methods: The rat PAR3 and 4 isoforms were cloned from a rat spleen cDNA library. PAR isoform mRNA expression was determined by using reverse-transcriptase polymerase chain reactions (PCR) in Sprague-Dawley rats. Confirmation of the identity of the amplified mRNA was done by sequence analysis. Relative quantification of the PAR1 and PAR2 isoforms was performed using a real-time quantitative reverse transcriptase PCR (RT-PCR) technique. PAR protein expression was confirmed by Western blots using polyclonal antibodies. Results: The rat PAR3 and 4 homologues showed significant sequence homology to the mouse and human amino acid and nucleotide sequences. The RT-PCR studies confirmed PAR1-4 expression in myometrium from rats in estrus. PAR3 was expressed in uterus, spleen, kidney, liver, lung, brain, and heart. PAR4 was expressed in uterus, spleen, and lung. Messenger RNA for the PAR1 and 2 isoforms was expressed during the second half of gestation in myometrium from timed-pregnant rats. In contrast, mRNA for the PAR3 and 4 isoforms was not detected in gestational myometrium. PAR protein expression appeared to match tissue mRNA expression patterns. Conclusion: These RT-PCR studies confirmed ubiquitous expression of the PAR1 and PAR2 isoforms in myometrium and other rat tissues; in contrast, the PAR3 and PAR4 isoforms are expressed in a tissue-specific and gestationally related pattern.

Thoracic Endometriosis Syndrome Resembling Pulmonary Embolism

A 32-year-old infertility patient with a previous diagnosis of stage IV endometriosis experienced shortness of breath and chest pain. She was diagnosed with a pulmonary embolism by spiral volumetric computed tomography (SVCT) and anticoagulated during hospitalization, although no history of thrombosis was ever identified. She continued to have intermittent symptoms of chest pain, back pain, and shortness of breath for the next 1.5 months. Repeat SVCT revealed a large, right-sided pleural effusion with associated consolidation but no evidence of pulmonary embolism. To obtain a definitive diagnosis, a thoracoscopic pleural biopsy was performed and showed thoracic endometriosis involving the pleura. The patient desired to retain her fertility and opted for treatment with depot medroxyprogesterone. She has been asymptomatic for 2 years with this treatment. This case illustrates the importance of recognizing thoracic endometriosis syndrome and the difficulty diagnosing this condition considering its nonspecific features.

Constitutive Androstane Receptor Expression in the Rat Cervix During Gestation

Objective: To investigate expression of the constitutive androstane receptor (CAR) in the pregnant rat cervix. Methods: Rat uterine tissue was obtained on gestational days 12, 16, 20, 21, and 22 (the day of parturition), and postpartum day 1. In addition, liver, lung, kidney, heart, and skeletal muscle tissue were obtained. Expression of the two known CAR isoforms was evaluated using reverse transcriptase-polymerase chain reaction. Results: These studies confirmed CAR expression in the liver; however, CAR was not demonstrated in the myometrium or cervical tissue. Conclusions: The currently described CAR1 and CAR2 isoforms are not expressed in rat uterine tissue; therefore, they do not appear to participate in parturition in the pregnant rat.