腹主动脉球囊预置术与髂内动脉球囊预置术在植入型凶险性前置胎盘治疗中的比较研究

目的:比较研究腹主动脉球囊预置术与髂内动脉球囊预置术在植入型凶险性前置胎盘治疗中的临床疗效。方法:选择2014年1月至2015年4月住院治疗的植入型凶险性前置胎盘患者64例,随机分为两组,择期剖宫产术前行腹主动脉球囊置管32例(腹主动脉组)和双侧髂内动脉球囊置管32例(髂内动脉组),观察比较两组孕妇术中、术后情况及新生儿出生和婴儿期生长发育情况。结果:两组患者在手术时间、术中出血量、术后最高体温、输血率、子宫切除率、住院时间、球囊预置术后穿刺部位出血率、感觉障碍发生率、新生儿Apgar评分、新生儿身高、出生体质量等方面比较,差异均无统计学意义(P0.05);而腹主动脉组球囊预置时间、透视时间、放射剂量均显著低于髂内动脉组(P0.05)。术后1年内随访,两组婴儿在42天、3个月、6个月、1年的体质量及身高情况比较,差异均无统计学意义(P0.05)。结论:腹主动脉球囊预置术与髂内动脉球囊预置术在植入型凶险性前置胎盘的治疗中均能安全、有效减少术中出血。而腹主动脉球囊预置术X线暴露时间更短、预判效果无需造影剂,对母胎保护性更强,可在临床推广。     

上推膀胱直肠后再次宫颈环形电切术对保留生育功能的价值

目的:探讨上推膀胱直肠后再次宫颈环形电切术(LEEP)在宫颈疾病治疗中的可行性,评价其对年轻患者保留子宫及生育功能的价值。方法:回顾性分析2010年1月至2014年4月在复旦大学附属妇产科医院就诊,因宫颈LEEP术后切缘阳性或术后随访复发、无法在门诊行常规LEEP而行上推膀胱直肠后再次LEEP的38例患者的临床资料。结果:38例患者均顺利完成了上推膀胱直肠后再次LEEP,术中均未出现膀胱、直肠损伤等并发症。手术时间38±7分钟,术中出血量20±5 ml,住院天数2.7±0.6天;其中1例患者术前病理检查为宫颈高度鳞状上皮内瘤变,术后升级为原位鳞癌合并原位腺癌行全子宫切除术,37例患者(97.4%)成功保留子宫,随访至今1例术后12个月低度鳞状上皮内瘤变行宫颈激光治疗,余均未见宫颈病变复发。12例患者有生育意愿,7例患者已成功妊娠,6例已分娩。结论:上推膀胱直肠后再次LEEP安全可行,可实现未生育妇女及年轻妇女保留子宫及生育能力的意愿。     

Responsiveness of gynecologic tumors to chemotherapeutic agents in the 6-day subrenal capsule assay

Various gynecologic malignancies have been tested in the 6-day subrenal capsule assay, which is an in vivo test of human tumor responsiveness to drug therapy. Fresh surgical explants of ovarian, endometrial, and cervical tumors were implanted as 1-mm³ fragments under the renal capsule of normal mice and tested against a spectrum of clinically active agents. Regardless of the site of origin, human tumors showed variations in growth rate when implanted under the renal capsule that appeared to reflect both the growth potential characteristic of each tumor as well as the heterogeneity of the cell populations comprising each tumor. An average of 60% of tumors showed positive growth and 11% demonstrated no measurable change in size. The response rates of 18 ovarian, 28 endometrial, and 20 cervical carcinomas to clinically active chemotherapeutic agents were determined. A range of responses, in terms of drugs indicated to be active and of the degree of responsiveness to active agents, was obtained with each histologic type. Response rates varied from 6% to tamoxifen in cervical carcinomas to 80% to 5-fluorouracil in ovarian carcinomas. The results of this study support the variability in chemotherapy responsiveness observed clinically with gynecologic tumors and suggest the feasibility of using the subrenal capsule assay as a predictive test.     

Laparoscopic Morcellator-Related Complications

Morcellation at laparoscopy is a commonly used minimally invasive method to extract bulky tissue from the abdomen without extending abdominal incisions. Despite widespread use of morcellation, complications still remain underreported and poorly understood. We performed a systematic review of surgical centers in the United States to identify, collate and update the morcellator-related injuries and near misses associated with powered tissue removal. We searched articles on morcellator-related injuries published from 1993 through June 2013. In addition, all cases reported to MedSun and the FDA device database (MAUDE) were evaluated for inclusion. We used the search terms “morcellation,” “morcellator,” “parasitic,” and “retained” and model name keywords “Morcellex,” “MOREsolution,” “PlasmaSORD,” “Powerplus,” “Rotocut,” “SAWALHE,” “Steiner,” and “X-Tract.” During the past 15 years, 55 complications were identified. Injuries involved the small and large bowels (n = 31), vascular system (n = 27), kidney (n = 3), ureter (n = 3), bladder (n = 1), and diaphragm (n = 1). Of these injuries, 11 involved more than 1 organ. Complications were identified intraoperatively in most patients (n = 37 [66%]); however, the remainder were not identified until up to 10 days postoperatively. Surgeon inexperience was a contributing factor in most cases in which a cause was ascribed. Six deaths were attributed to morcellator-related complications. Nearly all major complications were identified from the FDA device database and not from the published literature. The laparoscopic morcellator has substantially expanded our ability to complete procedures using minimally invasive techniques. Associated with this opportunity have been increasing reports of major and minor intraoperative complications. These complications are largely unreported, likely because of publication bias associated with catastrophic events. Surgeon experience likely confers some protection against these injuries. Understanding and implementing safe practices associated with the use of the laparoscopic morcellator will reduce these iatrogenic injuries.     

Histerectomía radical laparoscópica total en el cáncer de cérvix. Factibilidad,morbilidad y supervivencia

Objective

To assess feasibility, perioperative morbidity and medium term survival of total laparoscopic radical hysterectomy in cervical cancer.

Material and methods

A total of 31 consecutive patients diagnosed FIGO clinical stage IA2 (n = 4), IB1 (n = 22), IIA (n = 2) and IB2 (n = 3) in Son Llàtzer hospital (Palma de Mallorca) that were programmed for a total laparoscopic radical hysterectomy were studied. We analyzed tumor histological characteristics, surgical technique, perioperative variables, postoperative complications and mid-term survival results.

Results

Feasibility rate was 96%. The most frequently operative complication was accidental bladder incision (3 cases). Postoperative complications rate was 20% (6 cases) which includes one surgical reintervention. Average operative time was 258 minutes (range: 180-360). Blood transfusion rate was 17% (n = 5) and mean hospital stay was 7.8 days (range: 2-29). After one month after surgery 72% of patients had a normal miccional function. Mean tumoral size was 26.5 mm and lymphatic positive nodes rate was 17% (n = 5). Mean follow-up time was 26 months. Tumor relapse rate was 17% (n = 5) and survival-free disease of 100% for IA2 stage, 82.6% of IB1/IIA stages and 66.7% for IB2 stage.

Conclusions

Total laparoscopic radical hysterectomy is a feasible technique in most of the patients with cervical cancer. It needs more operative time than abdominal route but it presents less perioperative morbidity, less blood transfusion and less ospitalization days. The medium term survival is comparable with conventional abdominal route.     

~(18)F-FDG PET/CT检测妇科恶性肿瘤腹膜后淋巴结转移的临床价值

目的:探讨以18F-氟代脱氧葡萄糖(18F-FDG)作为示踪剂的正电子发射断层与X线计算机断层成像(18F-FDG PET/CT)对常见妇科恶性肿瘤腹膜后淋巴结转移的诊断及临床意义。方法:选择拟行手术治疗的妇科恶性肿瘤患者30例,所有患者术前均行18F-FDG PET/CT检查,然后行根治性手术。以手术病理结果作为对照,分别在患者水平和区域淋巴结水平计算18F-FDG PET/CT诊断妇科恶性肿瘤腹膜后淋巴结转移的敏感性、特异性、阳性预测值、阴性预测值及准确性。结果:30例患者术后病理证实原发灶均为妇科恶性肿瘤,12例患者存在腹膜后淋巴结转移,18F-FDG PET/CT正确诊断7例;在切除的199个区域淋巴结组中,经病理确认30个腹膜后淋巴结组发生转移,18F-FDG PET/CT正确诊断16个区域淋巴结组。在患者水平分析,18F-FDG PET/CT诊断腹膜后淋巴结转移的敏感性为58.3%,特异性为100.0%,阳性预测值为100.0%,阴性预测值为78.3%,准确性为83.3%;在区域淋巴结水平,上述指标分别为53.3%、98.8%、88.9%、92.3%和92.0%。发生淋巴结转移时,原发肿瘤的最大标准摄取值(SUVmax)要高于未发生淋巴结转移时,但两者差异无统计学意义(P=0.586)。结论:术前18F-FDG PET/CT显像诊断腹膜后淋巴结转移具有中度敏感性,不能代替全面手术病理分期;18F-FDG PET/CT诊断腹膜后淋巴结转移的高阳性预测值对是否进行全面手术分期有提示意义;较高的阴性预测值在选择不需要腹膜后淋巴结切除的患者时,也有一定的临床价值。     

宫腔镜下清宫术治疗剖宫产瘢痕妊娠前不同预处理方式的疗效分析

目的:探讨宫腔镜下清宫术治疗剖宫产瘢痕妊娠(CSP)前不同预处理方式的临床效果。方法:回顾性分析2014年10月至2015年10月本院住院中B超检查提示妊娠囊下缘距子宫切口小于1.0 cm行宫腔镜下清宫术并确诊为CSP的患者170例作为研究对象。其中直接行宫腔镜下清宫术的患者23例(A组);行米非司酮+米索前列醇药物治疗后在宫腔镜下行清宫术的患者29例(B组);行米非司酮+甲氨蝶呤+米索前列醇杀胚治疗后在宫腔镜下行清宫术的患者40例(C组);行子宫动脉灌注+介入栓塞术后在宫腔镜下行清宫术的患者78例(D组),比较4组患者治疗效果。结果:①所有患者手术顺利,无一例发生术中大出血和组织残留,4组患者治疗后血β-HCG较治疗前明显下降,术后血β-HCG、术中出血量、手术时间两两比较,差异无统计学意义(P0.05)。②A组和D组住院时间较短,B组和C组较长,A组与D组住院时间差异无统计学意义(P0.05),但其余两两比较,差异有统计学意义(P0.05)。③A组住院费用最少,D组最多,B组住院费用与C组比较差异无统计学意义(P0.05),但其余两两比较,差异均有统计学意义(P0.05)。④术后不良反应情况:A组术后无一例发生不良反应,B组术后有2例肝功能受损,3例恶心、呕吐等胃肠道反应,C组术后有3例肝功能受损,26例发生胃肠道反应;D组1例发生肝功能受损,16例发热,57例疼痛,对症治疗后好转。结论:CSP的治疗应根据患者病情、经济条件、个人意愿和医院的技术设备条件选择合适的治疗方案。     

Fístula cutáneo-uterina poscesárea

A fistula is an abnormal communication between two epithelial surfaces. Although fistulas that wrap around the uterus are not infrequent, uterocutaneous fistula is rare. The treatment of choice is abdominal hysterectomy with excision of the fistula up to the skin. We report two cases of uterocutaneous fistula requiring surgical treatment.