Hildoberto Carneiro de Oliveira

Risk factors for abdominal scar endometriosis after obstetric hysterotomies: a case–control study

Objective. to identify risk factors that are associated with the development of scar endometriosis after obstetric hysterotomies. The hypothesis is that early hysterotomy in pregnancy (before 22nd week) is the main risk factor for the development of scar endometriosis. Methods. The authors conducted a case–control study between April 2000 and June 2003. A total of 117 women were selected, including 39 cases and 78 controls. Exposure and confounding variables were measured by a standardized questionnaire, which included sociodemographic characteristics, reproductive/physiologic history, past pathological history, history of obstetric surgeries, family history, and social history. The odds ratio (OR) and its 95% confidence interval (CI) were calculated using bivariate analysis for each possible risk factor. These estimates were obtained by multivariate analysis using unconditional logistic regression. Tests were made to assess the fit of the final model. Results. In the multivariate analysis, positive assoc...Objective. to identify risk factors that are associated with the development of scar endometriosis after obstetric hysterotomies. The hypothesis is that early hysterotomy in pregnancy (before 22nd week) is the main risk factor for the development of scar endometriosis. Methods. The authors conducted a case–control study between April 2000 and June 2003. A total of 117 women were selected, including 39 cases and 78 controls. Exposure and confounding variables were measured by a standardized questionnaire, which included sociodemographic characteristics, reproductive/physiologic history, past pathological history, history of obstetric surgeries, family history, and social history. The odds ratio (OR) and its 95% confidence interval (CI) were calculated using bivariate analysis for each possible risk factor. These estimates were obtained by multivariate analysis using unconditional logistic regression. Tests were made to assess the fit of the final model. Results. In the multivariate analysis, positive associations were observed between scar endometriosis and hysterotomy type (early versus late: OR = 42.99; CI 8.77–210.81), amount of the menstrual blood flow (heavy versus light/normal: OR = 11.97; CI 2.35–60.82), and alcoholic consumption (yes versus no: OR = 5.31; CI 1.22–23.11). Negative association was observed between scar endometriosis and parity (OR = 0.61; CI 0.31–1.23), however it was not statistically significant (p>0.05). Conclusions. Early hysterotomy in pregnancy is the main risk factor for scar endometriosis. Increased menstrual flow and alcohol consumption are also risk factors, while high parity may be a protecting factor.

Bowel complications in endometriosis surgery

Endometriosis surgery by laparoscopy or laparotomy can be associated with various types of intestinal complications that may occur in the immediate postoperative period or later. They include bowel anastomotic dehiscence, rectovaginal fistula, anastomotic bleeding, intra-abdominal infections, wound infections, bowel stricture, intestinal obstruction, chronic constipation, and diarrhea. There is growing evidence that bowel injuries can be repaired by primary closure in two layers even without previous bowel preparation. Surgical treatments of deep bowel endometriosis include conservative surgery (including shaving technique or discoid resection) or a more radical approach such as bowel resection that is associated with increased complications. Good perfusion and no tension at the anastomosis site are essential when segmental resection is performed. Early recognition of bowel complications during surgery or in the immediate postoperative period is fundamental to decreased morbidity and mortality. This chapter will deal with the prevention of bowel complication in minimally invasive surgery for endometriosis.

A Simple and Effective Traction Device for Laparoscopic Formation of a Neovagina Using The Vecchietti Technique

We sought to present a simple new traction device that was used with success in 4 cases of laparoscopic creation of a neovagina using a modified Vecchietti technique. Four patients were treated with laparoscopic creation of a neovagina. All women had Rokitansky-Küster-Hauser syndrome and no more than a 1-cm vestibule dimple. A 3-cm diameter and 10-cm long plastic tube (mold) was used for traction. We developed 2 independent wood traction devices. They were based on tuning pegs of a guitar. The 1-cm demarcation in the external face of the mold allowed easy observation of the effects of traction. The patients were hospitalized from 7 to 10 days and the postoperative courses were uneventful. One patient was lost after 3 months of follow-up. After a year, the other 3 patients were having intercourse and were satisfied with the results. The laparoscopic technique has several advantages: it does not need grafts, it does not need a dissection of the space between the bladder and the rectum, it uses the mucous membrane of the vestibular area, the time of hospitalization is relatively short, and it possesses good long-term results.

Dilataçäo e curetagem na avaliaçäo do sangramento uterino anormal: achados histopatológicos e relaçäo custo/benefício

Purpose: to critically evaluate the histopathologic findings and the cost/benefit relation of dilatation and uterine curettage (D&C) in the evaluation of the abnormal uterine bleeding (AUB). Method: retrospective analysis of the histopathological findings in 542 D&C performed for AUB in the Department of Gynecology of the Faculdade de Ciencias Medicas da Universidade do Estado do Rio de Janeiro (FCM-UERJ), between January 1984 and January 1994. The patients were divided into two groups: Group 1 - patients £50 years (385 D&C) and Group 2 ¾ patients >50 years (157 D&C). Cases of urgency curettage were excluded from the study. All the curettages were accomplished under narcosis. The mean hospitalization lenght was three days. A histopa-thological finding of proliferative, secretory, atrophic or iatrogenic type endometrium was considered a negative pathological result. The term iatrogenic refers to the endometrium under possible influence of hormonal medication. When the histopathological finding evidenced some lesion, this was considered a positive pathological result. Results: in Group 1 there was a negative pathological result in 50.2% of the cases, positive pathological result in 39.7% of the cases, and insufficient material for diagnosis (IMD) in 10.1% of the cases. Endometrial polyp and submucosal leiomyoma were found in only 5.5% and 4.4%, respectively. Cancer was an uncommon observation in that group, endometrial adenocarcinoma (EAC) (five cases) being found in only 1.3% of the cases, in a relation of 77 D&C to one EAC. In Group 2, a negative pathological result was observed in 38.3% of the cases, positive pathological result in 38.1% of the cases and IMD in 23.6% of the cases. Endometrial polyp and submucosal leiomyoma were found only in 5.1% and 0.6%, respectively. Malignant lesions were found in 12% of the cases EAC being 9.5% (15 cases), showing a relation of one EAC to 10 D&C. Conclusions: according to the current knowledge on the etiology of AUB, this study showed that traditional diagnostic D&C has low accuracy in the evaluation of AUB and a cost/benefit relation incompatible with current medicine. Therefore, it should not be the examination of first choice. Considering, however, that EAC was found in one of each 10 D&C in women >50 years with a complaint of uterine bleeding, D&C can be indicated with more liberality in that group, if hysteroscopy with directed biopsy is not available. Nowadays, D&C does not play such a significant a role in the diagnosis of AUB as it did some years ago. However, the procedure is still indicated in some situations and it cannot be abandoned, and its indication should obey restricted criteria.

Terapia de reposição hormonal contínua na pós-menopausa: ênfase no hormônio do crescimento, insulina, fator de crescimento semelhante à insulina I (IGF-I) e proteína ligadora 3 do IGF (IGFBP-3)

The importance of the hormone replacement therapy (HRT) in the quality of life at the postmenopause is unquestionable. However not all the effects determinated by its use are well established yet. This study has the aim to evaluate the influence of the HRT on serum levels of the growth hormone (GH), insulin-like growth factor I (IGF-I), insulin-like growth factor binding protein 3 (IGFBP-3), glucose and insulin. We performed a controlled, prospective, longitudinal and comparative clinical trial, in which 53 natural or surgical postmenopausal women were submitted or not to a continuous HRT, during a 6 months period, with conjugated estrogens (CE-0.625mg/d) associated or not to the medroxiprogesterone acetate (MPA-2.5mg/d), by the oral route. The participants were subdivided in 3 groups: Group CE + MPA > composed by 20 women with uterus, who utilized CE and MPA; Group CE > composed by 20 hysterectomized women, who used CE; Group C > formed by 13 women, without HRT. Basal levels of GH, IGF-I and IGFBP-3 were measured in the beginning and at the end of the study. We have also performed a 2-hour oral glucose tolerance test (OGTT), with determination of glucose and insulin levels; area under curve (AUC) of glucose and insulin and insulin resistance index (IRI). The HRT use decrease the IGF-I levels in CE + MPA (p= 0.01) and CE (p= 0.0007), without change in the IGFBP-3 levels. The GH levels increased during the use of the HRT (EC + AMP: p= 0.004 e EC: p= 0.0003), however the serum concentrations of IGF-I and IGFBP-3 did not seem to be good markers of the circadian secretion of GH. At 6 months, it was noticed a negative correlation of the IGF-I with the AUC of glucose in the three groups (CE + MPA: r= -0.42, p= 0.06; CE: r= -0.58, p= 0.007 and C: r= -0.64, p= 0.01). The IGFBP-3 and the AUC of glucose showed a significant negative correlation in the group CE (r= -0.45, p= 0.04) and a tendency in CE + MPA (r= -0.42, p= 0.06). The association of MPA determined the appearance of IGT in 30% of the patients from the group EC + AMP (n= 6). Our results suggested an interaction between the carbohydrate metabolism with the IGF-I and IGFBP-3. The effects caused by the prolonged use of continuous HRT in the regulation of GH, IGF-I and IGFBP-3 still require elucidation.