Felix Neis

Dynamic adhesion of eryptotic erythrocytes to immobilized platelets via platelet phosphatidylserine receptors

Glucose depletion of erythrocytes triggers suicidal erythrocyte death or eryptosis, which leads to cell membrane scrambling with phosphatidylserine exposure at the cell surface. Eryptotic erythrocytes adhere to endothelial cells by a mechanism involving phosphatidylserine at the erythrocyte surface and CXCL16 as well as CD36 at the endothelial cell membrane. Nothing has hitherto been known about an interaction between eryptotic erythrocytes and platelets, the decisive cells in primary hemostasis and major players in thrombotic vascular occlusion. The present study thus explored whether and how glucose-depleted erythrocytes adhere to platelets. To this end, adhesion of phosphatidylserine-exposing erythrocytes to platelets under flow conditions was examined in a flow chamber model at arterial shear rates. Platelets were immobilized on collagen and further stimulated with adenosine diphosphate (ADP, 10 μM) or thrombin (0.1 U/ml). As a result, a 48-h glucose depletion triggered phosphatidylserine translocation to the erythrocyte surface and augmented the adhesion of erythrocytes to immobilized platelets, an effect significantly increased upon platelet stimulation. Adherence of erythrocytes to platelets was blunted by coating of erythrocytic phosphatidylserine with annexin V or by neutralization of platelet phosphatidylserine receptors CXCL16 and CD36 with respective antibodies. In conclusion, glucose-depleted erythrocytes adhere to platelets. The adhesive properties of platelets are augmented by platelet activation. Erythrocyte adhesion to immobilized platelets requires phosphatidylserine at the erythrocyte surface and CXCL16 as well as CD36 expression on platelets. Thus platelet-mediated erythrocyte adhesion may foster thromboocclusive complications in diseases with stimulated phosphatidylserine exposure of erythrocytes.

Evaluation of the HystSim™-virtual reality trainer: an essential additional tool to train hysteroscopic skills outside the operation theater.

BackgroundMinimally invasive surgery is a major pillar of gynecological surgery. However, there are very few training opportunities outside the operation theater (OR) due to the cost and equipment requirements of organ simulators, virtual reality trainers (VRT) are promising tools to fill this gap.MethodsExperienced and inexperienced participants of a minimally invasive surgery course followed the standardized HystSim™-VRT training program.ResultsPerformance of 39 Participants (15 inexperienced and 24 experienced) was evaluated in the standardized hysteroscopic program HystSim™. Tasks included three rounds of both a polyp and a myoma resection. Primary measurements were improvement in resection time, cumulative resection path length, and distention media use.ConclusionThe HystSim™-VRT is an effective tool to improve the psychomotor skills needed in hysteroscopic surgery for experienced and inexperienced surgeons prior to OR exposure. Additional organ models training is advisable for hysteroscopic haptic skills

Ultrasound guided core needle biopsy prior to thermo ablative treatment of uterine tumors: first results

PurposeThis study aimed at evaluating the diagnostic yield for core needle biopsies of uterine fibroids before laparoscopic radiofrequency volumetric thermal ablation (RFVTA) with the aim of sonographic imaging. This study was in the context of a randomized, prospective, single-center, longitudinal comparative study in which RFVTA and laparoscopic myomectomy for symptomatic uterine fibroids were compared.MethodsAll patients of the RFVTA-arm received a core needle biopsy under the guidance of an intraoperative laparoscopic ultrasound system. The Tissue samples were observed histologically.Results24 patients were included and received in the median 3.17 biopsies (range 2–7). 45.8% of the fibroids were intramural. In 92% uterine leiomyoma was detected, in 4% a cell rich leiomyoma and in 4% a smooth muscle tumor with uncertain malignant potential (STUMP). There were no complications caused by core needle biopsy.ConclusionsUltrasound guided core needle biopsy can be used to receive a histological result before treating uterine fibroids with thermo surgical methods like RFVTA.

Laparoscopic Supracervical Hysterectomy and Laparoscopic Total Hysterectomy in Patients with Very Large Uteri: a Retrospective Single-Center Experience at a Major University Hospital

Objective The main objectives of our study were to demonstrate that laparoscopic supracervical hysterectomy (LSH) or total laparoscopic hysterectomy (TLH) can be performed safely even in patients with a uterine weight ≥ 500 g, to analyze the rate of conversions to laparotomy due to uterine size and to estimate the incidence and type of intraoperative and long-term postoperative complications. Study Design Retrospective open, single-center, comparative interventional study of LSH and TLH. Results The present study comprised a total of 138 patients that underwent laparoscopic hysterectomy with a uterine weight ≥ 500 g; 109 patients (79.0 %) underwent LSH and 29 patients (21.0 %) underwent TLH. Median uterine weight across the entire cohort was 602 g, with the largest uterus weighing 1860 g. A total of 24 cases (17.4 %) among the 138 hysterectomies were converted to a laparotomy due to lack of adequate intraabdominal space and size of the uterus. Mean uterine weight of the patients in the LSH group that underwent conversion was 883 g (SD 380 g, n = 13) and 757 g (SD 371 g, n = 11) in the TLH group. The rate of conversion to laparotomy due to the uterine weight was significantly lower in the LSH group (11.9 %) compared to the TLH group (37.9 %) (p = 0.002). Intraoperative complications requiring laparotomy for other reasons but uterine size occurred in 6 patients of the study cohort (6/138; 4.3 %). Long-term postoperative complications occurred in 2 patients (2/138, 1.4 %), both patients from LSH group had to be re-operated on due to adhesions. Conclusions Our study adds further insight in the limited data set of laparoscopic hysterectomy for increased uterine weight and shows that LSH and TLH are safe and feasible even in patients with very large uteri (≥ 500 g).

Application of a Thulium Laser for Treatment of Cervical Neoplasias and Condylomas: A Feasibility Study.

OBJECTIVE Evaluation of safety, feasibility, and possibilities of the thulium laser, Vela(®), with a wavelength of 1.9 μm for laser treatment of the portio, vagina, and/or vulva. BACKGROUND DATA Laser techniques have been used for many years in the gynecological setting for the treatment of cervical, vaginal, and vulval intraepithelial neoplasias (CIN, VAIN, VIN) and also for the treatment of condylomas. To date, the most commonly used laser for this treatment is the CO2 laser. METHODS After indication was made for laser treatment, the patients were treated using the thulium laser, Vela. Follow-up examination usually took place after 1-2 weeks, 3 months, and 6 months, when colposcopy and, where necessary, a cytological smear were performed. RESULTS During the period from January 2012 to January 2014, 18 patients were treated using the thulium laser. Three patients had a CIN I, 12 had condylomas, two had CIN I and condylomas, and one had CIN II and condylomas. During the follow-up, 40% (n = 6) of patients had a relapse of condylomas. No relapse occurred in cases of CIN. Itching, burning, pain, bleeding, discharge, and skin irritation were listed as side effects of the procedure. CONCLUSIONS This feasibility study shows that the use of the thulium laser for the treatment of cervical neoplasias and condylomas offers a good alternative to the standard treatment using a CO2 laser.

Pathologies of the ischio-anal fossa: of gynaecological relevance?

The ischio-anal fossa is an uncommon localisation for pathologies. Pathologies described in the ischio-anal fossa comprise: fibromatous lesions, epidermal inclusion cysts, lipomas, posttraumatic haematomas, hernias and abscesses due to different implants/meshes used for pelvic floor reconstruction in urogynaecology. Pathologies in this area can cause discomfort such as dyspareunia, pressure sensation and pain in the pelvic floor area, also vaginal discharge, which causes patients to consult a gynaecologist. Even if these pathologies are rare, gynaecologists should be aware of their occurrence in order to diagnose and initiate appropriate care. The ischio-anal fossa is a fat-containing wedge-shaped region below the levator ani muscle, and extending from the perineal skin to the pelvic diaphragm. The lateral margin is the internal obturator fascia with the pudendal canal and posteriorly the fossa is bordered by the gluteus fascia [1]. Very fine structures go through this space, namely the inferior rectal arteries (deriving from the internal pudendal artery) and the inferior rectal nerve (deriving from the pudendal nerve) [1, 2]. The incidence of deep fibromatosis occurring in the Finnish population is 2–4 cases per million inhabitants per year in general [3]. In cases of fibromatosis, patients aged between puberty and their forties tend to be female, and the abdominal area is favoured. In childhood and later in adulthood, these tumours are equally distributed between abdominal and extra-abdominal locations and occur equally in both genders. In general, the tumours may occur almost anywhere, but most often the extremities, shoulders, chest wall, back, thighs, head and neck are involved. The pathogenesis is unknown, but multifactorial causes are assumed including genetic, endocrine and physical factors [4]. Trauma may also be a factor in the development of these tumours. Only a few case reports and case series of pelvic fibromatosis in the vulval region can be found in literature [5, 6]. The gold standard treatment is to resect the tumour with free margins [7]. However, the main goal during surgery is to guarantee the functional and structural integrity of the surrounding tissue [8]. If no free margins are achieved, the recurrence rate is high (24–77%). Radiation, hormonal therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), tyrosine kinase inhibitors and chemotherapy can be used if the desmoid is not resectable due to its location, if it could not be completely removed, or if it is recurrent [9]. The medical history of our 43-year-old patient suffering from increasing pelvic pressure and pain on her left side when seated was uneventful. She had undergone two episiotomies, the last one in 2003. The gynaecological examination revealed a 6 cm, round/ flat tumour extending from the left perineal area to the gluteal muscle (Fig. 1a). Rectovaginal palpation showed good tumour mobility with no detectable infiltration. The ultrasound and MRI examination showed a smooth-edged tumour in the ischio-anal fossa, measuring 7 × 6 × 6 cm with no signs of increased vascularisation or infiltration (Fig. 2a, b). The fibromatosis (105 g) was completely excised through a perineal incision after the vascular pedicle was coagulated (Fig. 1b, c), and no recurrence occurred. Epidermal cysts in the ischio-anal fossa are also very rare. If they occur in the vulvar region, they are usually found in the region of the clitoris [10, 11]. The aetiology includes trauma or surgical interventions such as episiotomy, as well as female circumcision in certain cultures [12]. Epidermal cysts normally are slowly growing cysts, which are symptomless until a critical size is reached when the cyst puts pressure on nearby organs. Gold standard treatment is the complete resection of the epidermal cyst. A 38-year-old patient presented with a tumour measuring 100 × 73 mm in the region of the right ischio-anal fossa. She complained about a strange feeling, and pain in the sacral area and in her back which had lasted for some months. * Christl Reisenauer christl.reisenauer@med.uni-tuebingen.de