J Radosa

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.

Estrogen, progesterone, and Her-2/neu receptor expression discrepancy in primary tumors and in-breast relapse in patients with breast cancer.

To the Editor: Estrogen and progesterone receptors have increasing importance in the management of breast malignancy. 60–70% of primary breast tumors are ER and PR positive. This results in a good prognosis for the patients (1) and allows the use of endocrine therapy which is now a standard in the adjuvant treatment of hormone receptor-positive invasive breast cancers. The hormone receptors are determined by immunohistochemistry on paraffin sections. Her-2/neu is a transmembrane tyrosine kinase receptor which belongs to the family of the EGFR. The most common reason of Her-2/neu overexpression in breast cancer is an amplification of the erbB2 gene. This results in a poor prognosis and occurs in 15–25% of all invasive breast cancers (2). The overexpression of Her-2/neu can be determined using immunohistochemistry and/or fluorescence in situ hybridization. Patients with Her-2/neu overexpressive breast cancer can be treated with the humanized antibody Trastuzumab. Some studies have reported hormone-receptor status discordance rates of 10–54% between primary and recurrent breast tumors (3–8). The mechanisms of change of hormone receptor and Her-2/neu expression have not been explicitly identified. Possible explanations include tumor heterogeneity, genetic instability, or errors in the determination of the receptors. Retrospective analysis was performed on 68 patients diagnosed with an in-breast relapse at the University Breast Center, Homburg/Saar, Germany, between 2001 and 2011. We evaluated the patient’s age at primary diagnosis and relapse, the tumor entity, the TNM stage, the initial grading and the grading at relapse, the ER-, PRand Her-2/neu status in primary cancer and relapse, the therapy received after the primary diagnosis. Primary and recurrent hormone receptor and Her-2/neu receptor data were obtained retrospectively using chart reviews or pathology reports. Sixty-one out of 68 patients showed an invasive carcinoma (89.7%) and seven cases a ductal carcinoma in situ. The patients had received surgical treatment or biopsy between 1982 and 2010 at University Breast Center, Homburg/Saar, in Germany. The age of patients ranged from 31 to 86. The mean time to the first recurrence of breast cancer was 7.7 years after the primary diagnosis. Thirty-three women were premenopausal and 35 were postmenopausal at the time of the first diagnosis. Overall, 64.7% of the primary breast cancers were positive for ER and PR. Only a few patients (3%) were Her-2/neu-positive at the time of the primary diagnosis. At this point of time, 31 patients were lymph node-negative, 32.4% had positive axillary lymph nodes and in 15 cases the nodal status was unknown. Patients had been treated either by lumpectomy in 47 cases or radical mastectomy in 21 cases plus axillary excision in form of axillary dissection in 50 cases or sentinel node dissection in seven cases. Most of the patients had received an adjuvant systemic therapy. Previous therapies included endocrine therapy for 40 out of 68 patients, previous chemotherapy for 38 out of 68 patients and previous radiotherapy for 35 out of 68 patients. Discordance rates between primary and locally recurrent lesions, were 23.5% for ER, 34% for PR, and 7% for Her-2/neu. In 13 cases, there was a switch from ER positive in the primary carcinoma to ER negative in in-breast relapse and in three cases the receptor changed from ER negative to ER positive. 25% of patients showed a PR-switch from positive receptor status in the primary carcinoma to a negative status in cancer relapse, and in 9% the PR status changed from negative to positive. The Her-2/neu receptor status shifted from negative to positive in four out of five patients comparing primary tumor and in-breast Address correspondence and reprint requests to: Russalina Mavrova, Saarland university Homburg Gynecology, obstretics and reproductive medicine, Kirrbergerstr. 100, Homburg Saarland 66421, Germany, or e-mail: r_mavrov@yahoo.de

Trial integration of combined ultrasound and laparoscopy tuition in an undergraduate anatomy class with volunteer participation — A pilot study

Anatomy is a cornerstone of medical undergraduate curricula. Due to increasing changes in various medical fields, a lot of new subjects were introduced in undergraduate curricula, while the teaching areas of basic sciences, i.e. anatomy, were reduced. The introduction of advanced diagnostic and therapeutic devices, i.e. ultrasound and laparoscopy, with outstanding imaging quality will be increasingly introduced in basic sciences. In our project, we examined the effect integrating ultrasound and laparoscopy in an anatomy undergraduate course to illustrate the female pelvis. Anatomy students that completed their practicum and cadaver dissection course were enrolled in our project. They received a theoretical introduction followed by a practical course of ultrasound or laparoscopy in the department of obstetrics and gynaecology. Following the course the students had to answer two questionnaires that evaluated their satisfaction, subjective knowledge-gain, problems and content of the course. At the end, a closing briefing was done to discuss the clinical skills and the course. The answers of the questionnaire were summed up in a Likert scale. 25 students were enrolled in the project. 52% attended laparoscopy operations, while 48% attended ultrasound examinations. After analysing the questionnaires using Likert scales (1=strongly agree, 5=strongly disagree) a general satisfaction of 1.5, a subjective knowledge gain of 2.4 and a thrive to extend these clinical skill programs in gynaecology and other specialities in basic science of 1.5 and 1.2, respectively, was reported. There were no statistically significant differences in the Likert scores between both groups (p>0.05). The introduction of ultrasound and laparoscopy in undergraduate basic science teaching programs is a promising method and should be further evaluated, standardized and expanded.

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.

Myxoiden Leiomyosarkom mit intravenöser Ausdehnung über die Vena cava bis zum rechten Vorhof – ein Case Report und Literaturrecherche

Einfuhrung: Das myxoide Leiomyosarcom des Uterus ist eine seltene Neoplasie, welche nur schwer vom Leiomyom abgrenzbar ist. Die Datenlagen zum Wachstumsmuster und der klinischen Manifestation sind begrenzt. Fallvorstellung: Wir berichten von einer 50-jahrige Patientin, welche konsiliarisch aus der Klinik fur Pulmologie vorgestellt wurde. Die Patientin war dort stationar mit Verdacht auf ausgedehnte Lungenarterienembolie bds. Ein durchgefuhrtes CT zeigte den V.a. eine Uterus-Neoplasie, DD Uterus myomatosus. Im transvaginalen Ultraschall zeigte sich im Douglas eine echoarme, unscharfe begrenzte 10 × 4 x 7 cm Raumforderung ohne Vaskularisation. In der durchgefuhrten MR-Angiografie zeigte sich ein Tumorzapfen von der rechten V. iliaca interna ausgehend bis in beide Lungenflugel reichend. Weiterhin wurde hierbei eine grose inhomogene, kontrastmittelaffine, infiltrativ wachsende, maligne Raumforderung im Becken, mutmaslich ausgehend vom rechten Ovar mit Infiltration der Vena iliaca interna rechts, festgestellt. Bei Verdacht auf uterines Leiomyosarkom erfolgte eine Langsschnittlaparotomie mit Hysterektomie, Adnexektomie beidseits, ein Tumorexstirpation Beckenwand rechts, sowie eine pelvine und paraaortale Lymphonodektomie und infracolische Omentektomie. Im intraoperativen Schnellschnitt konnten ein Sarkom nicht sicher ausgeschlossen werden. Zwei Tage spater erfolgte in der Herz-Thorax-Chirurgie eine erneute Operation mit Exstirpation des endovaskularen Tumorzapfens. In der endgultigen Histologie ergab sich ein finales Tumorstadium von pT2b pN0 (0/26) L0 V2 Pn0 R0 FNCLCC-Grad 1. Die Patientin erholte sich gut von der Operation und konnte am 12. postoperativen Tag entlassen werden. Bei R0-Resektion wurde die regelmasige Nachsorge empfohlen. Bisher ist die Patientin sechs Monate rezidivfrei. Zusammenfassung: Auch bei Vorliegen einer ausgedehnten intravasalen Ausbreitung ist eine R0-Resektion bei interdisziplinarer Herangehensweise moglich.