Gerhard Bogner

Single‐institute experience, management, success rate, and outcome after external cephalic version at term

To determine obstetric outcomes after external cephalic version (ECV) performed at term.

Breech delivery in the all fours position: a prospective observational comparative study with classic assistance

Abstract Objective: Vaginal delivery of fetal breech presentation is considered to be a challenge for obstetricians. The purpose of this study was to show that vaginal delivery in all fours position is feasible and safe for mother and child compared with vaginal breech and classic support. Methods: A single-center prospective observational case series of breech delivery (n=41) in all fours position was compared to a retrospective cohort of breech deliveries in the form of a matched-pair analysis. Results: Deliveries in the all fours position successfully took place without obstetric intervention in 70.7% of deliveries (n=29/41), and those including intervention in 90.2% (n=37/41). The rate of maternal perineal injuries was reduced (14.6% vs. 58.5%, P<0.001). Newborns delivered in all fours position had increased prenatal hypoxic stress with a pH of 7.19 [95% confidence interval (CI) 7.16–7.22] vs. a pH of 7.24 (95% CI 7.21–7.27; P=0.016). With n=24 vs. n=16, a higher number of newborns had a pH of <7.20 (P=0.03) and decreased base excess of –7.2 mmol/L (95% CI –8.2–6.2) vs. –4.8 mmol/L (95% CI –5.7–4.0; P<0.001). However, this had no clinical consequences for the newborns (5 min Apgar score <9: n=5 vs. n=4, not significant; transfer rate to neonatal intensive care unit n=7 vs. n=6, not significant). Conclusion: This is the first clinical evaluation of breech delivery in the all fours position. It is a feasible non-interventional obstetric delivery method. It seems to be safe for the fetus with reduced maternal morbidity. Vaginal delivery of fetal breech presentation, even in the all fours position, creates stress for the newborn.

Laparoscopic management of an unrecognized spontaneous bilateral tubal pregnancy

In industrialized countries, the incidence of ectopic pregnancy has increased sixfold over the past 30years, and is now estimated to be approximately 2% of all reported pregnancies (1). The rise in incidence has been attributed to improved methods in diagnosis and reporting, an increased frequency of pelvic inflammatory disease (2) and the growing importance of assisted reproductive techniques (ART). Bilateral ectopic pregnancy, however, is a rare condition, occurring at a ratio of 1/725–1/1580 ectopic pregnancies (3). Published some 60years ago, Fishback’s series of 76 cases of bilateral simultaneous tubal pregnancies probably represents the first comprehensive report on this topic (4). Compared with natural conception, the incidence of ectopic pregnancy in in vitro fertilization (IVF) programs is considerably higher with frequencies reported between 2% and 12.4% (5–7). The underlying mechanisms of this phenomenon are still discussed controversially. Of note, the first recorded pregnancy following IVF, reported by Steptoe and Edwards in 1976, was a tubal pregnancy in a woman with a known history of tubal damage (8). Tubal damage, however, is a major reason for women to seek treatment in IVF programs, and thus it is difficult to rule out the inherent risk of the IVF procedure per se. Clearly, the key to successful management of an ectopic pregnancy is early diagnosis. Given the current accuracy of different tests, algorithms using a combination of ultrasound and hCG testing provide the most favorable outcomes (9). We present a case of a bilateral tubal pregnancy; despite thorough preoperative work up including repeat ultrasound and serial hCG testing, correct diagnosis was not made until surgery.

The Reliability of Fetal MRI in the Assessment of Brain Malformations

Objectives: To assess the inter- and intraobserver reliability of different fetal MRI measurements in cases of fetal brain malformations and to examine the concordance between ultrasonography (US) and MRI findings. Methods: Fetal brain MRIs and US findings of 56 pregnant women were retrieved from the institutional database. Standardized fetal brain MRI measurements were performed by 4 observers, and the inter- and intraobserver reliability was determined. Additionally, US and MRI findings were retrospectively compared. Results: The interobserver intraclass correlation coefficient (ICC) was above 0.9 for the cerebellum and posterior horn of the lateral ventricle. The measurements regarding the third ventricle (0.50), the fourth ventricle (0.58), and the corpus callosum (0.63) showed poor reliability. Overall, the intraobserver reliability was greater than the interobserver reliability. US and MRI findings were discordant in 29% of the cases with MRI rendering an extended diagnosis in 18%, a change of diagnosis in 3.6%, and excluding pathological findings suspected on US in 7.1%. Conclusions: Fetal MRI is a valuable complement to US in the investigation of fetal brain malformations. The reliability of most parameters was high, except for the measurements of the third and fourth ventricles and the corpus callosum.

Relevance of Health Economics in Breast Cancer Treatment: Integration of Economics in the Management of Breast Cancer at the Clinic Level

Since the introduction of the diagnosis-related groups (DRG) system with cost-related and entity-specific flat-rate reimbursements for all in-patients in 2004 in Germany, economics have become an important focus in medical care, including breast centers. Since then, physicians and hospitals have had to gradually take on more and more financial responsibilities for their medical care to avoid losses for their institutions. Due to financial limitations of resources, most medical services have to be adjusted to correlating revenues, which results in the development of a variety of active measures to understand, steer, and optimize costs, resources and related processes for breast cancer treatment. In this review, the challenging task to implement microeconomic management at the clinic level for breast cancer treatment is analyzed from breast cancer-specific publications. The newly developed economic management perspective is identified for different stakeholders in the healthcare system, and successful microeconomic projects and future aspects are described.

Minimally invasive insufflation technique is and should not be a "black box" principle.

To the Editor: We read with great interest both recent articles by Bogani et al [1,2]. We congratulate the authors on their studies and support their statement that low-pressure pneumoperitoneum is feasible and safe for performance of laparoscopic hysterectomy and might even reduce pain. However, in the first article the authors give only limited and marginal information about the procedure, in which insufflation equipment was used (‘‘Veress needle,’’ ‘‘double-tubing insufflation,’’ ‘‘through both the umbilical port and the ancillary port,’’ and ‘‘insufflator was set at 20 L/ min’’) [1]. In the second article [2] they do not provide any information about the methods used, but only refer to the method described in the first article [1]. Neither the name of the insufflator is mentioned nor are the inner diameters of the tubes or insufflation supplies, or to be more specific, the smallest diameter plane available for insufflation at the insufflation supplies of trocars with and without instruments or optic inserted. Inasmuch as this is themost restrictive resistance for gas flow and the limitation of performance for the entire insufflation system, it affects gas flow rate and intraabdominal pressure settings of the insufflators. The size of optic inserted through the optical port remains unknown, as well as whether the 3-mm axillary port was used for insufflation only orwhether the diameter planewas evenmore reduced or even completely eliminated by the 3-mm instruments inserted. Naturally such resistance can affect pressure readings and consecutive pressure regulation of insufflators, and in case of a high gas flow resistance, mistake the overpressure in the insufflation system as intraabdominal pressure. Accuracy of insufflator settings or display readings clearly was not tested or verified in this study. On the basis of the methodologic description and information about the insufflation technique given, the studies and their results can neither be repeated nor verified by others. The actual intraabdominal pressure, the main parameter for their trial and its outcome, remains therefore an uncontrolled and unknown variable. Drawing conclusions on the basis of uncontrolled variables is scientifically not justified. The decision by Bogani and colleagues to exclude this technical information might be seen as a reasonable approach. However, for at least 2 decades it has been known that devices such as trocars and Veress needles have varying

Local Foreign Body Reaction of Peritoneum After Rupture of Cystic Partially Immature Teratoma

This is a pictorial report of rare sequelae after an unintended intraoperative rupture of a cystic teratoma. A 30-year-old woman was operated on for a mature cystic teratoma of the right ovary with an unintended intraoperative rupture of the ovarian tumor during the procedure. Postoperatively, the final immune histologic report showed partial neuroendocrine differentiation of an immature origin. At relaparoscopy for staging 7 weeks later, several suspicious peritoneal lesions of up to a 2.5-cm diameter were discovered and excised for which malignancy could not be excluded macroscopically. However, the final histologic report revealed a foreign body reaction related to spilling of the content of the mature teratoma. It is important to distinguish local peritoneal reaction from chemical peritonitis. The postoperative follow-up regarding symptomatic recurrence was uneventful.

Analyse ambulant durchführbarer Operationen einer Universitäts-Frauenklinik als ökonomische Entscheidungsgrundlage für die Einrichtung einer Operativen Tagesklinik

Fragestellung: Als strategische Entscheidungsgrundlage fur die Neueinrichtung einer Operativen Tagesklinik zur Auslagerung elektiv durchfuhrbarer Operationen ist eine Analyse der OP-Zahlen Voraussetzung. Arzte und Verwaltung definieren ambulante operative Leistungen unterschiedlich, gerade die Gynakologie hat viele Kleineingriffe, die entweder nicht elektiv sind oder nicht in der Kernarbeitszeit liegen. Zur Identifikation des tatsachlichen Potentials fur eine ambulante Operative Tagesklinik wurde alle OPs des Jahres 2012 ausgewertet, um eine wirtschaftliche Entscheidung abzuleiten. Methodik: Analyse aller OPs des Jahres 2012, die an Wochenarbeitstagen und in der Kernarbeitszeit von 7.30 – 15.30h durchgefuhrt wurden mit Identifikation aller ambulant durchfuhrbarer OPs wie diagnostische und operative Hysteroskopien (HSK), diagnostische Laparoskopien (LSK), Curettagen sowie andere kleine Eingriffe. Ausgeschlossen wurden operative LSK, Uro-Gyn- und Mamma-OPs sowie die Geburtshilfe. Aufgrund eingeschrankter Patienten-Compliance, Nicht-Elektivitat und fehlender postoperativer hauslicher Versorgung wurde eine tatsachlich ambulante Durchfuhrbarkeit mit 50% bzw. 75% angenommen und berechnet. Ergebnisse: Von n = 3.593 Eingriffen fanden n = 2.702 (75,2%) in der Kernarbeitszeit an Werktagen statt. Dabei wurden bei 1.658 Fallen O 1,6 Eingriffe durchgefuhrt, pro Monat O 138,2 (105 – 186) Eingriffe. Die Auswertung der maximal moglichen ambulanten Eingriffe ergab n = 258 diagnostische bzw. n = 31 operative HSK, n = 86 diagnostische LSK, n = 295 Curettagen sowie weitere n = 182 kleinere Eingriffe wie Konisation, Kondylomabtragung, PE, IVF, etc., zusammen n = 852 Eingriffe mit grundsatzlich ambulantem Potential. Bei 50% ambulanter Durchfuhrung waren dies n = 426 Falle bzw. bei 75% n = 639 Falle pro Jahr, bei 250 Wochenarbeitstagen sind dies n = 1,7 bzw. 2,6 Falle pro Tag. Schlussfolgerung: Patientinnen konnten von kurzerem Klinikaufenthalt durch eine Operative Tagesklinik profitieren. Auf Basis dieser Kalkulation sind aber pro Werktag in der Kernarbeitszeit nur 1,7 – 2,6 OPs fur eine Operative Tagesklinik als realistisch ansetzbar. Fur eine ausgelagerte Operative Tagesklinik sind diese Fallzahlen durch zusatzliche Investitionen und Personalaufwand unwirtschaftlich, so dass dies Konzept nur klinikintern innerhalb einer Frauenklinik sinnvoll umsetzbar erscheint. Voraussetzung fur ein integriertes Operatives Tagesklinik-Konzept sind u.a. Personalanpassung, Entwicklung von Protokollen fur optimalen Patienten-Flow fur Fast-Track-Surgery sowie Abrechnungsfahigkeit und ein durchgehendes telefonisches medizinisches Backup.

Erste Erfahrungen bei der nervenschonenden laparoskopischen radikalen Hysterektomie beim Zervixkarzinom

Fragestellung: Seit mehr als 25 Jahren wird die radikale Hysterektomie auf laparoskopischem Wege durchgefuhrt. Trotzdem wird an den meisten Abteilungen der Zugangsweg mittels Laparotomie der Laparoskopie vorgezogen. An Hand von Videosequenzen mochten wir die Technik der nervenschonenden laparoskopischen radikalen Hysterektomie beim Zervixkarzinom vorstellen und die Vorteile dieser Technik diskutieren. Methode: Sechs Patientinnen wurden mit dieser Technik bisher operiert, nachdem nach einer intensiven Lernphase an einem onkologischen Zentrum in Deutschland, diese Methode erlernt wurde. Die postoperative Morbiditat der Patientinnen insbesondere im Bezug auf die Blasenfunktion war deutlich geringer, bei allerdings zum Teil langerer Operationszeit im Vergleich zur offenen Technik. Ergebnisse und Schlussfolgerung: Die Darstellung der autonomen Nerven des kleinen Beckens gelingt mit den Vorteilen der Laparoskopie (z.B. Vergroserung, Gasdruck) unserer Meinung nach besser als bei der offenen Technik. Die Erhaltung der Nervi pelvini splanchnici und eines Grosteils des Plexus hypogastricus bedingt eine verminderte postoperative Morbiditat von Seiten der Blase und des Rectums. Diese Erfahrungen sind nicht nur fur onkologische Operationen relevant sondern auch bei ausgepragten Formen der Endometriose.