Giuseppe Trojano

Successful management of a cervical twin pregnancy: neoadjuvant systemic methotrexate and prophylactic high cervical cerclage before curettage.

OBJECTIVE To report our experience in managing a case of viable cervical twin pregnancy with systemic methotrexate and 2 weeks later with endocervical curettage after placing prophylactic high cervical cerclage. DESIGN Case report. SETTING University medical center. PATIENT(S) A 36-year-old woman, gravida 2, para 0, complaining of vaginal bleeding and pelvic pain, in whom cervical twin pregnancy was diagnosed at the sixth week of gestation. INTERVENTION(S) Systemic methotrexate was given as first-line treatment. Two weeks later because of persisting bleeding, endocervical curettage was performed after closing cervical arteries and placing but not tightening high cervical cerclage. MAIN OUTCOME MEASURE(S) Pregnancy termination, bleeding control, and preservation of fertility. RESULT(S) Notwithstanding the ligature of cervical arteries at curettage, heavy bleeding occurred, which was controlled rapidly by tightening the cerclage. Curettage then was completed successfully. Postoperative period was uneventful. Two years later the woman delivered vaginally. CONCLUSION(S) In case of cervical twin pregnancy methotrexate pretreatment and prophylactic placement of high cervical cerclage, but not ligature of cervical arteries, before curettage showed to be effective in terminating pregnancy ensuring effective bleeding control and preservation of fertility.

Kristeller maneuvers or fundal pressure and maternal/neonatal morbidity: obstetric and judicial literature review

Abstract Aim: A significant amount of data concerning maternal-fetal damage arising from the exertion of Kristeller maneuvers (KMs) or fundal pressure (FP) go unreleased due to medicolegal implications. Materials and methods: For this reason, the paper gathers information as to the real magnitude of litigation related to FP-induced damages and injuries. The authors have undertaken a research in order to include general search engines (PubMed-Medline, Cochrane, Embase, Google, GyneWeb) and legal databases (De Jure, Italian database of jurisprudence daily update; Westlaw, Thomson Reuters, American ruling database and Bailii, UK Court Ruling Database). Results: Results confirm said phenomenon to be more wide ranging than it appears through official channels. Several courts of law, both in the United States of America (USA) and in European Union (EU) Member States as well, have ruled against the use of the maneuver itself, assuming a stance conducive to a presumption of guilt against those doctors and healthcare providers who resorted to KMs or FP during deliveries. Given how rife FP is in mainstream obstetric practice, it is as if there were a wide gap between obstetric real-life and what official jurisprudence and healthcare institutions-sanctioned official practices are. Conclusion: The authors think that it would be desirable to draft specifically targeted guidelines or recommendations on maneuvers during vaginal delivery, in which to point out exactly what kinds of maneuvering techniques are to be absolutely banned and what maneuvers are to be allowed, and under what conditions their application can be considered appropriate.

A 5-mm trocar site paramedian early onset voluminous hernia: still in doubt?

With the increasing number of laparoscopies in abdominal surgery, more incisional trocar site hernias (ITH) are observed. Tonouchi et al. have classified trocar-site hernias into three types: early onset, late onset and special [1]. In most cases, the ITH had an early onset, occurring within the first week along with intestinal obstruction caused by ileal loop incarceration (Richter’s hernia). The case presented herein is of a 5-mm early onset ITH. The patient after a laparoscopic total hysterectomy with bilateral annessiectomy and peritoneal biopsies for an ovarian mucinous tumor of 14 cm was discharged on the third postoperative day. At the tenth postoperative day, she arrived at the emergency department, with pain in the left side, in which was observed an ITH of the small intestine with hemorrhagic infarction due to venous congestion. The patient was afebrile, without nausea and vomiting. Laboratory parameters were normal, except value of C-reactive protein, that result of 10 mg/dl (normal value < 1). The hernia sac was of 180 × 96 × 70 mm. The patient, after computer tomography scan (Fig. 1), was taken to the operating room. The site of hernia was extended and the small intestine was reduced. After observation of 10 min, peristalsis was regular, with improvement of the intestinal congestion. The peritoneum and fascia were closed with a 3-0 polyglactin running stitch with overlapping. However, mesh was not used because of required long skin incisions and wide surgical dissections, leading to high postoperative pain, wound complications, and long hospital stay and recent large population-based analysis failed to demonstrate any improved outcomes in the cure of incisional hernia. This is a rare preventable complication, because most ITH have developed at incisions 10 mm. The incidence of ITH ranges from 0.2 to 3.1%. In large case, series and reviews have been correlated to trocar size [2]. ITH, at a 5-mm port site are infrequently reported in the literature, are a rare but known complication of laparoscopic surgery. The main reasons are trocar diameter and design, pre-existing fascial defects, and some operationand patient-related factors. Currently, the accepted gynecologic surgical practice is closure of fascial incisions 10 mm, while incisions < 10 mm do not require closure. However, expert opinion and small case reports suggest that in cases of prolonged manipulation of 5-mm trocar sites the surgeon should consider fascial closure, because extension of the initial incision may have occurred. There have been ten published case reports of 5-mm trocar hernias. The largest number of 5-mm cases, for a total of 5 of 11 ITH, is a retrospective case review of 5300 patients [3]. Para-median locations versus median locations have been associated with conflicting rates of ITH reported in the literature. The linea alba, including the umbilicus, lacks the muscle support in spontaneous fascial closure due to the lack of rectus muscle. Paramedian incisions have been shown to be supported by muscle re-opposition after blunt trocars were used (Level 2) not requiring fascial closure [4]. The arcuate line demarcates an inherent weakness. The internal oblique and the transversus abdominis of the posterior rectus migrate to join the anterior sheath, leaving only the transversalis fascia for support to the rectus. Extensive manipulation of the trocar port site and fascial and peritoneal stretching with prolonged manoeuvres, emergency situations, may widen a port-site incision beyond. Risk factors, such as chronic bronchitis or weight increase, give rise to endoabdominal pressure. Malnutrition may have a major role. There is a likelihood of an increase in the onset of ITH * Gianluca Raffaello Damiani damiani14@alice.it

Unilateral twin tubal pregnancy: a case report and review of the literature.

BACKGROUND Unilateral twin tubal pregnancy is an extremely rare condition, occurring in 1/20.000-250.000 pregnancies and represents a major health risk for reproductive-aged women, leading to even life-threatening complications. AIM We present a case of a 31-year-old woman with unilateral twin tubal pregnancy, treated with methotrexate and then surgically because of failure, followed by review of the literature. METHODS Researches for relevant data were conducted utilizing multiple databases, including PubMed and Ovid. RESULTS The most common type of twin ectopic pregnancy is the heterotopic (1/7000 pregnancies) in which in which both ectopic and intrauterine pregnancy occur simultaneously. Expectant, medical and surgical therapy have similar success rates in correctly selected patients. Two prospective randomized trials did not identify any statistically significant differences between groups receiving MTX as a single dose or in multiple doses. Among the 106 cases reported in literature, methotrexate was tried just in 4 patients (3 unilateral and 1 bilateral) before ours. Details are reported in the table 1. CONCLUSION The recent shift in the treatment of singleton ectopic pregnancies to the less invasive medical therapy might apply even in the case of twin implants.

Evaluation of the cervix tissue homogeneity by ultrasound elastography in infertile women for the prediction of embryo transfer ease: a diagnostic accuracy study

BackgroundUltrasound elastography is a non-invasive medical imaging technique able to quantitatively characterize the stiffness of a given tissue. It has been shown to predict the risk for cervical insufficiency and preterm delivery, and to allow differentiation of malignancy from normal tissue. The present study sought to evaluate whether cervical tissue dishomogeneity, as assessed by cervical ultrasound elastography, may predict the embryo transfer (ET) ease in infertile women undergoing IVF/ICSI.MethodsWe evaluated 154 infertile patients with no history of previous ET or intrauterine insemination. Cervical stiffness was evaluated in six regions of interest (ROI), compared two by two to obtain strain ratio (SR) values. Since a SR value of 1 was suggestive of tissue homogeneity, we computed 1-SR/SR-1 values to obtain a measure of the degree of cervical tissue dishomogeneity that we named “dishomogeneity index” (DI). Ultrasound-guided ET was performed by an expert operator blinded to the results of cervical elastography. The prediction ability of elastography on ET ease was evaluated by binary logistic regression, and the predictive accuracy of the independent variables was quantified with area under the curve (AUC) estimates derived from receiver operating characteristic (ROC) curve.ResultsET resulted to be easy in 99 out of 154 patients (64,2%), difficult in 54 patients (35%), and impossible in one. DI values in cervical medial lips region correctly classified 86.9% of patients, according to binary logistic regression, with a sensitivity of 81.4% and a specificity of 89,9%, positive likelihood ratio (LR) 8.07 and negative LR of 0.21. A DI cut-off value of 0.29 predicted a difficulty of ET with a sensitivity of 88,9% and a specificity of 85%.ConclusionsCervical ultrasound elastography, by allowing the identification of cervical tissue dishomogeneity, may be of help in predicting the ET ease in infertile women candidates to IVF/ICSI.

Diagnosis of Tailgut Cyst in Gynecologic Patients: Systematic Review of the Literature

Tailgut cysts, also called retrorectal cystic hamartomas, are rare findings that usually occur in the retrorectal space. The incidence is estimated to be about 1 in 40,000. The aim of our review is to evaluate the potential pitfalls in the diagnosis of this rare pathologic condition, according to diagnostic procedures for this rare but misleading and subtle entity. We conducted a Medline literature review of the English literature discussing tailgut cysts in female patients. We concentrated on imaging technology used for diagnosis in gynecologic patients. For our search, we used the key words “tailgut cyst”, “retrorectal cystic hamartoma”, “gynecology”, focusing on clinical presentation, imaging technology used for diagnosis, presence of malignancy, and misdiagnosis with more common gynecologic pathology. Our search revealed 143 articles during the years 1975–2016 and, of these, 30 articles describing 91 female patients were considered. We concluded that tailgut cyst should be included in the differential diagnosis of pelvic lesions in gynecologic patients.

Comparison of Robotic and laparoscopic Radical type-B and C hysterectomy for cervical cancer: Long term-outcomes.

STUDY OBJECTIVE To compare the clinical and oncologic outcomes of Robotic radical hysterectomy (RRH) vs Laparoscopic radical hysterectomy (TLRH) in patients with cervical carcinoma. DESIGN Long term follow-up in a prospective study between March 2010 to March 2016. SETTING Oncological referral center, department of gynecology and obstetrics of Alessandro Manzoni Hospital, department of gynecology, University of San Gerardo Monza, Milan. PATIENTS 52 patients with cervical carcinoma, matched by age, body mass index, tumor size, International Federation of Gynecology and Obstetrics (FIGO) stage, comorbidity, previous neoadjuvant chemotherapy, histology type, and tumor grade to obtain homogeneous samples. INTERVENTIONS Patients with FIGO stage IA2 or IB1 with a tumor size less than or equal to 2 cm underwent RR type B. RR-Type C1 was performed in stage IB1, with a tumor size larger than 2 cm, or in patients previously treated with NACT (IB2). In all cases Pelvic lymphadenectomy was performed for the treatment of cervical cancer. MEASUREMENTS AND MAIN RESULTS Surgical time was similar for both the 2 groups. RRH was associated with significantly less (EBL) estimated blood loss (P=0,000). Median number pelvic lymph nodes was similar, but a major number of nodes was observed in RRH group (35.58 vs 24.23; P=0,050). The overall median length of follow-up was 59 months (range: 9-92) and 30 months (range: 90-6) for RRH and TLRH group respectively. Overall survival rate (OSR) was 100% for RRH group and 83.4% for LTRH group. The DFS (disease free survival rate) was of 97% and 89% in RRH and LTRH group respectively. No significant difference was reported in HS (hospital stay). CONCLUSIONS RRH is safe and feasible and is associated with an improved intraoperative results and clinical oncological outcomes. The present study showed that robotic surgery, in comparison to laparoscopic approach, was associated with better perioperative outcomes because of a decrease of EBL, and similar operative time, HS and complication rate, without neglecting the long-term optimal oncologic outcomes.