Tsung-Hsien Su

Prospective comparison of laparoscopic and traditional colposuspensions in the treatment of genuine stress incontinence

Objective. To compare prospectively the results of laparoscopic and traditional colposuspensions in the treatment of genuine stress incontinence and to evaluate the efficacy, technique, and functional and anatomical changes after these two procedures.

Parallel vertical compression sutures: a technique to control bleeding from placenta praevia or accreta during caesarean section

Fourteen women with placenta praevia (including one who also had placenta accreta) undergoing caesarean section had massive bleeding after removal of the placenta. In order to preserve the uterus, two parallel vertical compression sutures were placed in the lower segment to compress the anterior and posterior walls of the lower uterine segment. The haemorrhage from the lower segment stopped immediately after the knots were tightened. All women later resumed normal menstrual flow with no apparent complications. Two of the 14 women had a spontaneous pregnancy one to two years after the operation. This parallel vertical compression suturing technique is simple, easy and effective for controlling bleeding in women with placenta praevia or accreta. We suggest that this technique be tried first before other more complex procedures are undertaken.

Neuroendocrine carcinoma of the uterine cervix : A clinicopathologic retrospective study of 31 cases with prognostic implications

Abstract The present study describes 31 clinical cases of neuroendocrine cervical carcinoma (NECC) treated at Mackay Memorial Hospital between January 1, 1991 and October 31, 2003. There are two cases of atypical carcinoid tumor (ACT), four cases of large-cell neuroendocrine carcinoma (LCNEC), and 25 cases of small-cell neuroendocrine carcinoma (SCNEC). Overall survival did not differ significantly in relation to surgery, tumor histology, age, FIGO stages, chemotherapeutic regimens or lymph node involvement. The specimens available did not permit HPV (human papillomavirus)-DNA analysis in 5 cases (5/31, 9.7%). The HPV viral infection was absent in 8 cases (8/31, 26%); 17 cases of HPV-18 (17/31); and 1 case of HPV-16 (1/31). The prognosis between mixed and pure type histologic patterns is not significant. The mean survival time for all patients was 32.3 months. The 2-year and 5-year survival rates were 54.8% and 31.5% for all patients. The results of this study reaffirm the biologically aggressive nature of this rare malignancy, its low survival rate, and its very unpredictable prognostic factors. Effective treatments of neuroendocrine cervical tumor still remain inconclusive. Further efforts are still required to identify prognostic factors for this uncommon disease.

Acute pancreatitis in pregnancy

BACKGROUND Acute pancreatitis in pregnancy is rare. Our purpose in this study was to discuss the etiology, incidence and course of pancreatitis in pregnancy and to evaluate the maternal and perinatal outcomes. METHODS Pregnant women with pancreatitis admitted to China Medical College Hospital, Taiwan, from 1980 to 1995 were studied retrospectively. A total of 16 patients were enrolled in the study. Two patients had gallstones and hyperlipidemia; four had gallstones alone; seven had hyperlipidemia alone; one had gestational diabetes mellitus; one had hyperparathyroidism and pregnancy-induced hypertension alone; and one had Hashimotos thyroiditis. Conservative treatment and low-fat diets were administered to the patients. RESULTS The incidence of gestational pancreatitis in this series was one in 6,790 pregnancies. The fetal outcome included eight preterm deliveries and three fetal losses. There were no maternal mortalities. The etiologies of pancreatitis were primary hyperlipidemia (56.3%) and gallstones (37.5%). All patients responded favorably to supportive therapy, and most of the symptoms subsided after delivery. CONCLUSIONS Early diagnosis and treatment is of utmost importance in the management of acute pancreatitis in pregnancy. The results of this study showed good maternal outcome following appropriate treatment. Fetal prognosis was less favorable and was most often associated with hyperlipidemia. Fetal monitoring is essential during the management of pancreatitis in pregnancy.Objective. The highest maternal–fetal risk from pancreatitis in pregnancy is likely to be posed by the most severe cases, which we have compared with mild cases. Design. Retrospective observational study. Setting. A general surgery department of a university referral hospital in Nanjing, China. Population. Eighteen pregnancies complicated with severe acute pancreatitis and 51 pregnancies complicated with mild acute pancreatitis. Methods. Medical records were reviewed for every pregnant woman with mild or severe acute pancreatitis during January 1999 to December 2009. Main Outcome Measures. Information on demographics, clinical and laboratory data, maternal and fetal outcomes. Results. Gestational age of onset was significantly higher in the severe acute pancreatitis group than in the mild acute pancreatitis group. Severe hypertriglyceridemia was considered the main cause of severe acute pancreatitis (OR 20.7; 95% CI 4.6–92.4, p<0.001), while biliary disease contributed to the etiology of mild acute pancreatitis (OR 7.3; 95% CI 1.8–30.1, p<0.01). Abortions and preterm infants contributed to fetal loss in the mild group, while fetal death and stillbirth contributed in the severe group. Conclusions. Hyperlipidemic pancreatitis and biliary pancreatitis are the main causes of severe and mild disease, respectively. Severe acute pancreatitis in pregnancy usually occurs in the third trimester, and the affected severe patients are more liable to develop a critical condition that results in higher risk of intrauterine fetal death.

Risk factors for failure of transvaginal sacrospinous uterine suspension in the treatment of uterovaginal prolapse.

BACKGROUND AND PURPOSE The purpose of this study was to elucidate the risk factors for failure of transvaginal sacrospinous uterine suspension (SSUS) in the treatment of uterine prolapse and to examine methods for controlling these risk factors. METHODS Sixty patients with second degree uterine prolapse or greater were included in this 2-stage study, with 33 in the risk factor assessment and 27 in the clinical study of a modified treatment to eliminate identified risk factors. Patients were followed for at least 5 years. The first part of the study evaluated the risk factors for operative failure and the efficacy of the operative procedure. The second part of the study evaluated a modified treatment plan to eliminate risk factors identified in the first part of the study. RESULTS The failure rate for those with an elongated cervix (3 of 4, 75%) and those with third degree uterine prolapse (3 of 4, 75%) was significantly higher than for patients without either of these risk factors (6.9%, 2/29) [p = 0.007]. Concomitant partial trachelectomy for those with elongated cervix significantly reduced the failure rate from 75% to 0% (0/7) [p = 0.024]. In the risk factor study, SSUS was successful in 84.8% (28/33) of patients. In the clinical study of modified therapy to prevent significant risk factors, the success rate was 96.3% (26/27). CONCLUSIONS This study found that an elongated cervix and third degree uterine prolapse were the 2 main risk factors for recurrent uterine prolapse after SSUS. Concomitant partial trachelectomy as an adjuvant treatment of SSUS for treatment of uterovaginal prolapse in patients with an elongated cervix significantly reduces the rate of failure in these patients.

Laparoscopic para‐aortic lymph node sampling in the staging of invasive cervical carcinoma: including a comparative study of 21 laparotomy cases

Objectives: To assess the efficacy and risks of laparoscopic para‐aortic lymph node sampling compared with standard laparotomy in staging cervical carcinoma. Methods: From August 1993 through July 1994, 38 patients with biopsyproven invasive cervical carcinoma (24 early and 14 advanced invasive cancers) were entered into the study. This was a prospective study of laparoscopic para‐aortic lymphadenectomy in invasive cervical carcinoma, with patients serving as their own controls. Video laparoscopic lymph node sampling was performed. In patients with early invasive cancer, the nodes were sent for frozen section and, if negative, laparotomy was performed to look for any residual nodes. Radical hysterectomy was performed immediately if residual nodes were negative. Patients with either nodal metastasis on frozen section or with advanced cancer underwent para‐aortic lymphadenectomy only. The operative technique was also evaluated. Results: Laparoscopy required an average of 77 min (S.D. 40), with an average blood loss of 116 ml (S.D. 321). The average number of nodes was 15 (S.D. 7). At subsequent laparotomy the average number of residual nodes found was 0.4 (S.D. 0.9) and none showed metastasis. One vena cava laceration and one ureteral injury required immediate repair, and two patients were too obese to undergo laparoscopy. Conclusions: Laparoscopic para‐aortic lymph node sampling is a less invasive, reliable method for staging invasive cervical carcinoma and can substitute for traditional open procedures. The incidence of risks with this method appears to be low.

Acute Fatty Liver of Pregnancy in a Taiwanese Tertiary Care Center: A Retrospective Review

OBJECTIVE To evaluate the demographics, clinical presentations, laboratory findings, and maternal and fetal outcomes in patients with acute fatty liver of pregnancy. MATERIALS AND METHODS A retrospective review was conducted of the records of pregnant patients with a diagnosis of acute fatty liver in a tertiary medical center over a 22-year period. RESULTS Eighteen patients with acute fatty liver of pregnancy were recruited, all of whom developed the disease in the third trimester. Eleven women (61%) were primigravid and four (22%) had twin pregnancies; six (33%) were diagnosed antepartum, and the other 12 (67%) were diagnosed postpartum. There were two maternal deaths (11%) and four fetal deaths (18%). The most common complications apart from severe liver dysfunction were acute renal failure (83%), hypoglycemia (61%), and disseminated intravascular coagulation (61%). CONCLUSION Women who become acutely ill during the third trimester of pregnancy should undergo tests for acute fatty liver of pregnancy, including laboratory tests for assessing liver function and coagulation profile.

Concurrent Cisplatin-Based Chemoradiation for Cervical Carcinoma: Tumor Response, Toxicity, and Serum Cytokine Profiles

Purpose. To evaluate the relation between tumor response, treatment toxicity, and serum cytokine profiles in patients with cervical cancer receiving cisplatin-based chemoradiation. Patients and Methods. Forty-two patients with cervical carcinoma receiving chemoradiation were recruited. Hemogram, biochemistry profile, cytokine levels, tumor size, and toxicity were assessed weekly. Results. The absolute neutrophil count decreased accompanied by an increase in serum levels of G-CSF during chemoradiation. The sudden elevation of serum TGF-β 1 and VEGF levels after the first fraction of brachytherapy accompanied with the development of greater radiation therapy (RT) morbidity. Lower pretreatment TGF-β 1 and VEGF levels are associated with tumor response to chemoradiation. Conclusion. The serial changes in serum cytokines during chemoradiation may correlate with tumor regression and treatment morbidity.

Laparoscopic management of interstitial pregnancy

Interstitial pregnancy is relatively rare accounting for only 2—4% of all ectopic pregnancies. Conventionally it is treated by laparotomy with cornual resection or hysterectomy. Conservative medical management consists of systemic or local injection of methotrexate with an overall success rate of 83%. However if the serum h-hCG decreases slowly or the gestational sac continues to grow despite methotrexate surgery must be considered. Laparoscopic cornuostomy causes less cornual trauma than open surgery. However hemorrhage remains a major problem and has been the main cause of failure in this procedure. Most techniques use diluted intramyometrial vasopressin in the affected cornu to minimize blood loss. Bipolar electrocauterization tamponade with Surgicel fibrin glue and ligation of the ascending uterine artery have all been tried but these are not always sufficient to control hemorrhage particularly at the placental implantation site. (excerpt)

A conservative surgical treatment of cervical pregnancy with active bleeding ‐ uterine artery ligation and cervicotomy

Cervical pregnancy complicated with massive bleeding usually results in abdominal hysterectomy, and thus the patient loses her fertility potential. Conservative management to control active hemorrhaging as well as to preserve reproductive function is necessary for women who desire more children. We present four patients with cervical pregnancy, complicated by life threatening hemorrhage, who were successfully treated with uterine artery ligation and cervicotomy. Subsequently, one patient had two successful term pregnancies delivered by cesarean section.