Ingolf Juhasz-Böss

Abdominal surgery in pregnancy--an interdisciplinary challenge.

BACKGROUND Abdominal operations are performed during ca. 2% of all pregnancies. They represent an unusual situation not only for the patient, but also for the involved surgeons and anesthesiologists. Appendectomy, followed by cholecystectomy are the two most common types of operation performed during pregnancy. Special questions arise with regard to the peri- and intraoperative management and the optimal surgical approach. METHOD This review is based on pertinent articles retrieved by a selective search in the PubMed database. RESULTS The question of laparoscopy versus laparotomy during pregnancy has been addressed to date only in case series and a few meta-analyses. Two meta-analyses have shown a significantly higher rate of miscarriage after laparoscopic, compared to open, appendectomy (relative risk [RR] 1.91, 95% confidence interval [CI] 1.31-2.77). The risk of preterm birth is also somewhat higher after laparoscopic appendectomy according to one meta-analysis on this subject (RR 1.44, 95% CI 0.78-1.76), but significantly lower according to another meta-analysis (2.1% vs. 8.1%, p<0.0001). For cholecystectomy, laparoscopy was associated with a lower miscarriage rate than laparotomy (1 in 89 cases, versus 2 in 69 cases), but with a somewhat higher preterm birth rate (6 in 89 cases, versus 2 in 69 cases). Delay or non-performance of surgery in a patient with appendicitis or cholecystitis can lead to additional hospitalizations, a higher miscarriage rate, premature rupture of the membranes, and preterm birth. CONCLUSION Laparoscopy in experienced hands is safe even during pregnancy, with the recognized advantages of minimally invasive surgery, yet it carries a higher miscarriage rate than laparotomy, with a comparable preterm birth rate. Before surgery, patients should be thoroughly informed about the operation they are about to undergo and the advantages and disadvantages of the available surgical approaches.

Laparoscopic and laparotomic approaches for endometrial cancer treatment: a comprehensive review.

ObjectiveEndometrial cancer (EC) is the most common gynecological malignancy in the developed world, particularly among postmenopausal women. Endoscopic surgery is gaining more popularity among surgeons as a safe and feasible option for treatment of endometrial carcinoma, providing the possibility of adequate lymph node excision.MethodsA comprehensive review.ResultsThe advantages of laparoscopy prevail over laparotomy and authors report lower peri-operative complication rates, less blood loss, lower transfusion rates, and shorter hospital stay, as well as a better quality of life (QoL) after laparoscopic surgery, in contrast to conventional abdominal surgery. This was confirmed by a meta-analysis of four randomized controlled studies. This is also true for obese risky patients to whom laparotomies carry indolent side effects. In addition, with more training and experience this procedure would be even more feasible and safer.ConclusionsBecause of the increasing importance of economic efficiency in health care, the endoscopic approach will continue to play a more important role in the future treatment of EC providing a better treatment option for the coming patients. As a promising therapeutical option, it should be offered to all patients with an early-stage EC.

Matrix metalloproteinase messenger RNA expression in human endometriosis grafts cultured on a chicken chorioallantoic membrane

OBJECTIVE To investigate the role of matrix metalloproteinase 1 and 2 (MMP-1/MMP-2) in human endometrial explants in a chicken chorioallantoic membrane model (CAM) of endometriosis. DESIGN Experimental prospective study. SETTING University hospital. PATIENT(S) Endometrium samples obtained from ovulating women, both healthy and patients with endometriosis, who were undergoing curettage and diagnostic laparoscopy for benign gynecologic conditions. INTERVENTION(S) Endometrial grafts were transplanted to the CAM and cultured for 0, 24, 48, 72, and 96 hours. MAIN OUTCOME MEASURE(S) Expression of MMP-1 and MMP-2 messenger RNA (mRNA) was quantified by competitive reverse-transcriptase polymerase chain reaction (RT-PCR) and normalized to expression of the housekeeping gene human glyceraldehyde 3-phosphate dehydrogenase (GAPDH) mRNA. RESULT(S) All grafts expressed MMP-1 and MMP-2 mRNA. The endometrium of healthy women and patients with endometriosis showed a statistically significant increase of MMP-1 mRNA expression 24, 48, 72, and 96 hours after transfer to the CAM. An increase of MMP-2 mRNA expression was only detected after 96 hours of CAM culture in patients with and without endometriosis. No statistically significant difference regarding the MMP-1 and MMP-2 mRNA expression could be shown in healthy women or endometriosis patients. CONCLUSION(S) Our data suggest that MMP-1 and MMP-2 are major factors involved in the invasion of endometrium into the peritoneum and in vascularization of endometriosis. Whether MMPs are suitable targets for treatment of endometriosis has to be examined in further studies.

The treatment of rectal endometriosis and the role of laparoscopic surgery.

Purpose of review Rectal endometriosis is a very indolent disease whose treatment has been debated by a range of competing schools. Meanwhile, not all audiences in the scientific community are entirely familiar with the full aspects of the disease. Hence, the purpose of this review is to outline the basic as well as the recent literature pertaining to the disease, thus offering a broader view to the interested reader. Recent findings Laparoscopic shaving or disc excision for rectal endometriotic nodules may be simple, safe options of controlling the disease. On the contrary, laparoscopic rectal resections, originally reserved for more extensive disease, are now more skillfully mastered by surgeons and gynecologists. Meta-analyses, retrospective, and prospective studies are being published frequently supporting one form of therapy at a time and discrediting another at other times. Summary Laparoscopic shaving or disc excisions for rectal endometriotic foci or rectal resections are feasible and efficient methods for treating rectal endometriosis. More complex surgery to the bowel means more risk for complications. With the rising learning curve of the operators, laparoscopic rectal resections have become a safe option that should be offered to patients. The patients preference to a particular treatment option should be central to the type of surgery to be elected.

Expectations for endoscopic training during gynaecological specialty training - Results of a Germany-wide survey

Question: Endoscopy is an integral part of surgical gynaecology and is playing an increasingly important role in ensuring adequate gynaecological training in the context of specialty training in general. At present, little is known about the expectations and notions of young junior doctors with respect to endoscopic training. For this reason, junior doctors throughout Germany were surveyed on this topic and asked to share their opinions. Methods: Using an anonymized standardized survey, the following information was elicited: importance of endoscopic training, willingness to take courses, expectations for instructors and the hospital, ideas about the number of required operations, both as a surgical assistant and as a surgeon, as well as satisfaction with the current status of training. The questionnaires were sent via the Young Forum (Junges Forum) of the German Society of Gynaecology and Obstetrics (DGGG) and the newsletter of the Working Group for Gynaecological Endoscopy (AGE). Results: The evaluation of the study was based on 109 completed questionnaires. The resident junior doctors were 31 years old on average and were in their third to fourth year of their specialty training on average. The majority of the participants (87 %) considered the learning of endoscopic techniques to be very important and advocated regular participation in endoscopy training courses. Among the participants, 48 % were prepared to invest up to €1500 of their own funds to attend courses up to twice a year during the entire specialty training period. The expectations of the instructors and institutions focused on technical expertise, the willingness and time for teaching and on the number and range of surgical procedures, followed by being granted leave for the courses and having costs covered for the courses. Thirty-eight per cent stated that their expectations had been completely or mostly met and 62 % said they had been met in part or inadequately. Eighty-three per cent of the respondents reported that they would change specialty training institutions in order to achieve their own goals in the context of specialty training. Conclusions: This study presents data for the first time on the satisfaction of young junior doctors and their expectations for endoscopic specialty training. The residents exhibited a high level of interest in endoscopy and a high level of willingness to actively shape the specialty training, including course participation. However, there appears to be a great deal of room for improvement for endoscopic specialty training, independent of the current training institution, training year or sex of the junior doctors.

Laparoskopische Eingriffe in der Gynäkologie

ZusammenfassungDie Laparoskopie stellt für Patienten ein schonendes und wenig belastendes Operationsverfahren dar und hat in den letzten Jahrzehnten stark an Bedeutung gewonnen. Heutzutage werden minimal-invasive Verfahren sowohl zur Diagnostik als auch zur Therapie der meisten gynäkologischen benignen und malignen Erkrankungen angewandt. Ähnlich den Vorteilen, welche diese Methode bietet, bestehen auch zugangsspezifische intra- und postoperative Komplikationen. Über diese speziellen Komplikationen im Rahmen laparoskopischer gynäkologischer Operationen gibt die Arbeit einen Überblick und stellt Maßnahmen sowie Algorithmen und klinische Standards zur Prävention, zur Diagnose und zur Therapie derselben vor.AbstractDuring the past decades, laparoscopic techniques have gained more and more significance as minimally invasive treatment options. Nowadays, these procedures are used for diagnosis and treatment of most benign and malignant gynecological diseases. In addition to the advantages of minimally invasive techniques, access-specific intra- and postoperative risks and complications also exist. This article gives an overview of complications in laparoscopic gynecologic procedures, and introduces measures, algorithms, and clinical standards for the prevention, diagnosis, and treatment of these.

Two novel classification systems for uterine fibroids and subsequent uterine reconstruction after myomectomy

ObjectiveLaparoscopic approaches are the gold standard surgical treatment for intramural and subserous fibroids, whereas submucosal myomas can be treated via hysteroscopy. Removal of intramural myomas often requires a subsequent reconstruction of the uterine wall that ranges from single- to multiple-layer sutures to complex reconstructions. Several classification systems are currently used to characterize uterine fibroids, all of which focus on the assessment of submucosal fibroids during hysteroscopic myomectomy. There are no classification systems for the comprehensive localization of fibroids or for uterine reconstruction after myomectomy. Therefore, the aim of this study was to validate a new scoring system developed by our group to classify uterine leiomyoma as well as a standardized assessment scoring system for uterine reconstruction after surgical myomectomy.Methods/PatientsTo validate the uterine fibroid and uterine reconstruction classification systems, a retrospective review of 136 patients undergoing surgical myomectomy and uterine reconstruction at a single tertiary institution was performed. The age of the patient, duration of surgery, number, size, and location of excised fibroids, number of uterine incisions, level of uterine reconstruction, desire for future pregnancies, pre- and postoperative hemoglobin concentrations, duration of postoperative hospitalization, and operating surgeon were obtained by medical chart review. For each patient, a specific fibroid score and the level of uterine reconstruction were determined according to the classification systems. Correlations between the uterine fibroid and reconstruction scores, as well as between the classification scores and perioperative parameters, were analyzed.ResultsThe newly developed classification system for uterine fibroids incorporates the number, location, and size of myomas, as well as the number of uterine incisions required for myomectomy. The uterine reconstruction scoring system comprises four levels of reconstruction, ranging from no reconstruction to advanced reconstruction. Outcomes from 136 patients showed a correlation between uterine fibroid and uterine reconstructive scores. High fibroid scores were correlated with higher levels of reconstruction. Both scoring systems showed associations with the duration of surgery, intraoperative blood loss, and days of hospitalization.ConclusionsThis study presents the first scoring system for uterine fibroids that incorporates all possible fibroid locations and a standardized assessment of uterine reconstruction. Scoring systems were validated in a large cohort, and a correlation was identified between uterine fibroid and uterine reconstruction scores. In daily clinical practice, this scoring system allows a better planning of surgery, specifically of the estimated duration of surgery, blood loss, and time of hospitalization.

Abdominal Hysterectomy: Postoperative Care

Optimal postoperative care is an important step of surgical treatment, especially after open surgery as in case of abdominal hysterectomy, which can be associated with various postoperative complications. A standardized management is recommended to minimize postoperative complications and avoid a prolonged hospitalization of the patient. In this chapter we point out the most common complications of abdominal hysterectomy and give an overview of preventive and treatment options.

Abdominal Hysterectomy: Indications and Contraindications

Hysterectomy is the most common non-obstetric gynecologic procedure and remains the gold standard for treatment of benign uterine pathologies and part of the surgical treatment of gynecologic malignancies. Many guidelines have been published regarding the best technique to perform hysterectomy and although overall recommendations endorse a vaginal or minimal invasive approach whenever feasible, the largest proportions of hysterectomies worldwide are performed via laparotomy. This chapter gives an overview of the indications and contraindications of abdominal hysterectomy and introduces factors which influence the choice of the route of hysterectomy.

Dickkopf-1 (Dkk1) protein expression in breast cancer with special reference to bone metastases

Dysregulation of the Wnt inhibitor dickkopf-1 protein (Dkk1) has been reported in a variety of cancers. In addition, it has been linked to the progression of malignant bone disease by impairing osteoblast activity. This study investigated serum- and tissue levels of Dkk1 in breast cancer patients with- or without bone metastases. Serum Dkk1 levels were measured by ELISA in 89 breast cancer patients and 86 healthy women. Tissue levels of Dkk1 and β-catenin, a major downstream component of Wnt transduction pathway, were tested with immunohistochemical staining in 143 different tissues, including adjacent non-tumoral breast tissues, primary breast tumours, lymph nodes metastases, and bone metastases. Serum levels of Dkk1 were significantly increased in breast cancer patients without metastases compared with healthy controls and even more increased in patients with bone metastases. Tissue expression of Dkk1 was positive in 70% of tested primary breast cancer tissues and demonstrated significant correlation with histological type and PR status. Less frequent expression of Dkk1 was found in lymph nodes metastases and bone metastases compared with adjacent non-tumoral breast tissues and primary breast tumours. Tissue expression of β-catenin was positive in the vast majority of all tested tissue types indicating activated Wnt/β-catenin signalling. Our results suggested that Wnt/β-catenin signalling in breast tumours and their secondary lymph nodes- and bone metastases is dysregulated and this could be related to aberrant Dkk1 expression levels. Hence, Dkk1 protein might provide insights into the continued development of novel comprehensive and therapeutic strategies for breast cancer and its bone metastases.