Masaaki Nagamatsu

Hyperemesis Gravidarum in Eastern Asian Population

Objective: To investigate the clinical features of hyperemesis gravidarum in Eastern Asian women. Method: Retrospective cohort study was conducted based on delivery records. Hyperemesis gravidarum was defined as a pregnancy with severe nausea and vomiting necessitating hospitalization with a body weight loss of over 5% from pre-pregnancy weight with ketonuria. The onset is at 10 weeks of gestation or less. Maternal and neonatal variables were compared. Result: There were 3,350 singleton deliveries in the study period. All subjects were Eastern Asian women. Hyperemesis gravidarum was observed in 119 cases (3.6%). Hyperemesis gravidarum subjects had a smaller pre-pregnancy body weight (50.5 ± 0.64 kg vs. 51.8 ± 0.16 kg, p = 0.046) and a smaller pre-pregnancy body mass index compared to non-hyperemetic subjects (20.2 ± 0.21 kg/m2 vs. 20.8 ± 0.06 kg/m2, p = 0.02). Conclusion: The Eastern Asian population had a significantly higher incidence of hyperemesis gravidarum. Small pre-pregnancy body habitus increased the risk of hyperemesis gravidarum.

A phase II study of combination chemotherapy using docetaxel and irinotecan for TC-refractory or TC-resistant ovarian carcinomas (GOGO-OV2 study) and for primary clear or mucinous ovarian carcinomas (GOGO-OV3 Study)

OBJECTIVE To analyze the efficacy and safety of combination chemotherapy of docetaxel and irinotecan for paclitaxel and carboplatin (TC) -refractory or -resistant ovarian carcinomas and for first treatment of primary clear cell and mucinous ovarian carcinomas. STUDY DESIGN Between 2002 and 2009, we conducted a prospective Phase II study of the efficacy and safety of combination chemotherapy using docetaxel and irinotecan in 62 patients with TC-refractory or -resistant ovarian carcinoma cases (GOGO-OV2) and 15 patients with primary clear cell and mucinous ovarian carcinoma cases (GOGO-OV3). The dose of docetaxel and irinotecan was determined during our previous Phase I study. RESULTS A docetaxel plus irinotecan regimen provided a 53% response rate, 6 months progression-free survival (PFS), and 12 months overall survival (OS) for primary clear cell and mucinous ovarian carcinomas (similar to TC therapy). The differences of anti-tumor and survival effects between refractory and resistant cases were not statistically significant. The regimen also provided a 15% response rate, 5 months PFS, and 15 months OS for TC-refractory or TC-resistant cases, when used as a second-line chemotherapy. These data are similar to previous reports, however, our study provides the first data exclusively for the cases refractory or resistant to a gold standard TC therapy as a second-line chemotherapy. The regimen was demonstrated to be well tolerable. CONCLUSION Combination chemotherapy of docetaxel and irinotecan may be a useful option to treat TC-refractory/resistant cases and primary clear cell and mucinous adenocarcinoma cases of ovarian carcinoma.

Maternal urinoma during pregnancy

Urinoma is peripelvic extravasation of urine seen as the squeal of urinary trauma or stones. Little is known about maternal urinoma during pregnancy. A 27‐year‐old primigravida presented with gradual worsening right flank pain at 215/7 weeks of gestation. She denied any past medicosurgical history. Initial work‐up revealed cost‐vertebral angle tenderness and mild hydronephrosis by ultrasonography. Her symptom worsened and follow‐up ultrasonography was performed 48 h later, which showed worsened hydronephrosis with large perinephric fluid collection. A Double‐J stent was placed under cystoscopy. After the placement, the patients symptoms improved quickly. The stent was removed three weeks later. The patient delivered vaginally at 39 weeks of gestation without complication. Maternal urinoma during pregnancy developed in the right side of the kidney in five of six reported cases (83.3%), and all were seen in the second half of pregnancy. All showed flank pain as the initial presentation. Ultrasonography for diagnosis was used in half of the patients. Fifty percent underwent Double‐J stent before delivery and 16.7% after delivery. All cases delivered at term and 33.3% underwent cesarean delivery. Maternal urinoma is an important differential diagnosis for flank pain during pregnancy. Double‐J stent placement was the main management. Close monitoring of the symptom with serial ultrasonography may be the key for diagnosis.

Clinical Significance of Atypical Squamous Cells of Undetermined Significance among Patients Undergoing Cervical Conization.

BACKGROUND Atypical squamous cells of undetermined significance (ASCUS) feature a wide variety of cervical cells, including benign and malignant examples. The management of ASCUS is complicated. Guidelines for office gynecology in Japan recommend performing a high-risk human papillomavirus (HPV) test as a rule. The guidelines also recommend repeat cervical cytology after 6 and 12 months, or immediate colposcopy. The purpose of this study was to determine the clinical significance of ASCUS. MATERIALS AND METHODS Between January 2012 and December 2014, a total of 162 patients underwent cervical conization for cervical intraepithelial neoplasia grade 3 (CIN3), carcinoma in situ, squamous cell carcinoma, microinvasive squamous cell carcinoma, and adenocarcinoma in situ at our hospital. The results of cervical cytology prior to conization, the pathology after conization, and high-risk HPV testing were obtained from clinical records and analyzed retrospectively. RESULTS Based on cervical cytology, 31 (19.1%) of 162 patients were primarily diagnosed with ASCUS. Among these, 25 (80.6%) were positive for high-risk HPV, and the test results of the remaining 6 patients (19.4%) were uncertain. In the final pathological diagnosis after conization, 27 (87.1%) and 4 patients (12.9%) were diagnosed with CIN3 and carcinoma in situ, respectively. CONCLUSIONS Although ASCUS is known as a low-risk abnormal cervical cytology, approximately 20% of patients who underwent cervical conization had ASCUS. The relationship between the cervical cytology of ASCUS and the final pathological results for CIN3 or invasive carcinoma should be investigated statistically. In cases of ASCUS, we recommend HPV tests or colposcopic examination rather than cytological follow-up, because of the risk of missing CIN3 or more advanced disease.

Etiology of Ascites and Pleural Effusion Associated with Ovarian Tumors: Literature Review and Case Reports of Three Ovarian Tumors Presenting with Massive Ascites, but without Peritoneal Dissemination

Borderline ovarian tumors are benign but relatively large tumors that are often initially mistaken as ovarian cancers. We report three cases of stage I borderline ovarian tumors having massive ascites that we (preoperatively) suspected of being advanced ovarian cancer. The three patients (35, 47, and 73 years old) reported feeling fullness of the abdomen before consulting their gynecologist. By CT scan, they were diagnosed with a pelvic tumor accompanied by massive ascites, the diameters of which were 11, 20, and 11 cm, respectively. Postsurgical pathology showed all were stage I borderline ovarian tumors without dissemination; two were mucinous and one was serous. The amount of ascites was 6,300, 2,600, and 3,600 mL, respectively, and was serous in all. Cytodiagnosis of the ascites found that one was positive for tumor cells and two were negative. After resection of the mass, the ascites disappeared in all three cases. No pleural effusion was present at any time. The literature is reviewed concerning ascites and pleural effusions linked to ovarian tumors, and a supposition is forwarded of why pleural effusion presents sporadically in these cases.

Can Triclosan-Coated Sutures and the Use of Double Gloves Reduce the Incidence of Surgical Site Infections?

Background: Postoperative surgical site infections (SSIs) are one of the most frequent complications after open abdominal surgery. Triclosan-coated sutures were said to be able to reduce its occurrence. In gynecologic surgery, SSIs of the vaginal stump are a frequent cause of postoperative fever. Double gloving is also said to contribute to the prevention of SSIs. We performed abdominal hysterectomy with double gloving and sutured the vagina stump with VICRYL PLUS ® , a Polyglactin 910 suture coated with triclosan, to prevent SSIs. We investigated whether triclosan-coated sutures coupled with double gloving could indeed reduce the incidence of SSIs following abdominal hysterectomy. Methods: We retrospectively reviewed 384 cases of abdominal hysterectomies operated in our department between April 2013 and March 2015. In the first period (from April 2013 to March 2014), we performed 195 operations with single gloving and sutured the vaginal stump with VICRYL ® (Polyglactin 910 suture without triclosan coat). In the second period (from April 2014 to March 2015), we performed 189 operations with double gloving and sutured the vaginal stump with VICRYL PLUS ® (Polyglactin 910 suture with triclosan coat). The primary outcome is the incidence of SSIs. Results: The two groups were comparable with respect to risk factors for SSIs. The incidences of SSIs in the first and second groups were 17 of 195 patients (8.7%) and eight of 189 patients (4.2%), respectively. The difference in the incidence of SSIs was not significant between the two groups (P = 0.097). The numbers of cases requiring postoperative antibiotic therapy in the first and second groups were 13 (6.7%) and 4 (2.1%). The incidence was higher in the control group (P = 0.045). None of the 189 cases needed drainage therapy or a re-operation. Conclusion: It is possible that triclosan-coated sutures coupled with double gloving are able to reduce SSIs and prevent SSI aggravation. J Clin Gynecol Obstet. 2017;6(1):1-5 doi: https://doi.org/10.14740/jcgo429w

The pressure symptom identical to rare malignant psoas syndrome after ovarian transposition: a case report

Adjuvant pelvic irradiation will be often applied after cervical cancer operation, despite inducing permanent ovarian damage. For the preservation of ovarian function, ovarian transposition is usually operated in premenopausal women with early-stage cervical cancer. The development of ovarian cysts is the most frequent complication after ovarian transposition. However, the pressure symptom exerted by ovarian cysts is not a usual symptom of ovarian cysts which occur in transposed ovary. Here we report a rare case of ovarian cysts of transposed ovary, presenting symptoms identical to rare malignant psoas syndrome, which refers to pain induced by ipsilateral psoas major muscle involvement of malignant disease. And the symptom was probed to be induced by the lutein cyst after ovarian transposition and radical hysterectomy. The patient was a 43-year-old woman, gravida 1, para 1, who underwent radical hysterectomy and ovarian transposition for early cervical cancer in another hospital. Two years after the operation, bilateral ovarian cysts of transposed ovaries were pointed out. They were not considered as a recurrence as specific tumor markers were within the normal range and the up-take was not recognized in PET-CT. She stated to experience hip and pubic pain when the ovarian cysts were 5 cm. Due to difficulties controlling her pain, we performed a laparoscopic operation for the diagnosis. A swollen left ovary was observed on the iliopsoas in the retroperitoneal space. It was not twisted or ruptured. We performed left adnexectomy and adhesiolysis and her pain resolved after the operation. The pathologic diagnosis was a lutein cyst.

Case report of a rare pure uterine lipoma treated by laparoscopic hysterectomy

We herein present a case of a pure lipoma, arising from the uterine fundus, coincidental with an ovarian tumor. Both masses were successfully resected with laparoscopy. A 60-year-old woman (gravida 3, para 2) was referred to our hospital with both an ovarian and a uterine tumor, which were found by her physician during a routine physical checkup. Her past medical history contained nothing particular to this event. Importantly, she did not present with any related symptoms, such as abdominal pain or abnormal genital bleeding. The patients serum tumor markers for CA125, carcinoembryonic antigen (CEA), and CA19-9 were all in the normal range, and her uterine cervical cytology was negative. Transvaginal ultrasonography revealed a hyperechogenic tumor (25 mm in diameter) in the fundus of the uterus (Figure 1). Transvaginal ultrasonography showed a second mass (55 mm in diameter), containing both hyperechogenic and isoechogenic regions, in the right ovary. Magnetic resonance imaging (MRI) was applied to investigate the ovarian tumor; it also described the tumor in the uterine myometrium, with a high intensity pattern in both the T1/T2 weighted sequences, and the MRI signal dropped out in the fat suppression series. The tumor of the uterus was preoperatively suspected of being a lipoleiomyoma, lipoma, or some other neoplastic malignancy. The contents of the right ovarian tumor were suppressed in the MRI fat suppression series. This suggested that the ovarian tumor was a mature cystic teratoma (Figure 2). Laparoscopy-assisted vaginal hysterectomy and bilateral salpingo-oophorectomy were performed. The gross weight of the combined uterus and left adnexa was 118 g. The gross findings for the posterior uterine wall showed a yellow-colored soft tumor of 25 mm in diameter (Figure 3). The contents of the right ovarian tumor were hair and fatty tissue (figures not shown). Microscopic examination of the posterior uterine wall showed atrophic endometrium with an intramural tumor composed of benign mature adipose tissue. The tumor was clearly delineated from the normal myometrium and no smooth muscle cells or fibrous elements were seen within the tumor (Figure 4). The final histopathology confirmed a diagnosis of a pure lipoma of the uterus, and of a mature cystic teratoma of the right ovary. The patient has since recovered, without any complications, and she was discharged on the 8th postoperative day.

Rare hydrosalpinx in a sexually inactive adolescent successfully treated with laparoscopy

The majority of cases of symptomatic hydrosalpinx needing treatment are caused by sexually transmitted diseases. However, here, we present a rare case of a hydrosalpinx occurring in a sexually-inactive adolescent girl successfully treated with laparoscopy. A 17-year-old girl presenting with lower abdominai symptoms had a surgical history for an inguinal hernia at infancy. Transabdominal ultrasonography revealed a multicystic lesion in the pelvis, and magnetic resonance imaging suggested hydrosalpinx. Due to the abdominal pain and a suspicion of torsion, laparoscopic surgery was performed. After aspiration and resection of a cystic tumor, we confirmed that the left ovary was normal and that the tumor involved the left fallopian tube, which was twisted at the isthmus. Although relatively rare in postmenarchal sexually inactive adolescents, clinicians and surgeons must still consider hydrosalpinx as a possible diagnosis when encountering an adolescent patient with lower abdominal pain.

Gemella morbillorum bacteremia following total laparoscopic hysterectomy for uterine corpus cancer

Gemella morbillorum, a Gram-positive coccus facultative anaerobe, is part of the normal flora of the mucous membranes of the oropharynx, upper respiratory, gastrointestinal, and female genital tracts. However, this species can also cause serious infection. We herein report on a case of bacteremia, accompanied by peritonitis and pleuritis, in a 46-year-old immunocompetent female following a total laparoscopic hysterectomy for endometrial cancer. The case was successfully treated with antibacterial and antifungal agents.