A review of 80 endometrial resections for menorrhagia.

OBJECTIVE--To assess the efficacy of endometrial resection in treating menorrhagia. DESIGN--A clinical audit of 80 consecutive patients. SETTING--The department of gynaecology, Ealing Hospital, London. SUBJECTS--Eighty women referred by their general practitioner with the primary complaint of menorrhagia. INTERVENTIONS--Endometrial resection by hysteroscopic electro-diathermy. MAIN OUTCOME MEASURES--Subjective assessment of the change in menstrual blood loss by the 75 patients, who were followed up for at least one year. RESULTS--Of 75 women assessed after 1 year 45 (60%) had a successful outcome and nine (12%) had 'some improvement'. There were 21 failures; 14 reported 'no improvement' initially and seven were late failures after a good result at 6 months. Fifteen underwent a second procedure with 83% success at 6 months. Complications included uterine perforation in three women, excessive glycine absorption in two, and two women had problems with haemorrhage. Four women came to hysterectomy. CONCLUSIONS--Endometrial resection is an effective treatment for menorrhagia. Improvements in operative technique and equipment gave better results and fewer complications in the second half of the series.     

Hepatic adenoma and focal nodular hyperplasia.

Hepatic adenoma and focal nodular hyperplasia are benign lesions of the liver. The incidence of these conditions has been increasing since 1970. Hepatic adenoma primarily affects young women of childbearing age who have a long history of using oral contraceptives, while focal nodular hyperplasia has a wider age distribution and is not associated with the use of oral contraceptives. The most extensive complication of hepatic adenoma is intratumoral or intraperitoneal hemorrhage, which occurs in 50 to 60 per cent of patients. Patients with focal nodular hyperplasia are usually asymptomatic and rarely experience complications. Hepatic adenoma is distinct from focal nodular hyperplasia both in its clinical behavior and its pathologic features; the two can usually be differentiated radiographically using a combination of radionuclide scanning and angiography. There is a proved association between the use of oral contraceptives and the development of hepatic adenoma; the longer the duration of oral contraceptive use, the more the risk of having hepatic adenoma develop. In addition, users of oral contraceptives who have hepatic adenoma develop are likely to have larger tumors and higher rates of bleeding and rupture than nonusers who have hepatic adenoma develop. Although hepatic adenomas may regress after discontinuation of oral contraceptive use, this is not a consistent finding. In addition, it has now been demonstrated that hepatic adenomas do undergo malignant transformation and that this can be detected by measuring the alpha-fetoprotein level. Focal nodular hyperplasia may be a precursor for fibrolamellar hepatocellular carcinoma. Elective resection of hepatic adenoma has a mortality rate of less than 1 per cent, while the mortality rate with free rupture is 5 to 10 per cent. Because of the relative safety of elective versus emergency resection and the potential for malignant change, the treatment of choice for hepatic adenoma is surgical resection.     

Hepatic vein and portal vein Doppler ultrasound of maternal liver in normal pregnancy

Objective: The purpose of our study was to evaluate the changes occurring in maximum flow velocity and waveform patterns of the portal and hepatic veins during pregnancy in second and third trimesters.

Methods: A total of 204 patients were randomly divided into the study and control groups. The control group was classified as group I; the study group was divided into two groups: group II, second trimester pregnancy (14–26 weeks, n?=?91) and group III, third trimester pregnancy (26–40 weeks, n?=?63). Vein waveforms were classified as triphasic, biphasic and monophasic.

Results: Maximum flow velocities of both right hepatic vein and main portal veins were lower in group III compared with group I and group II (p?<?0.05). On the basis of hepatic vein and portal vein waveforms, the incidence of biphasic pattern was prominent in group II (p?<?0.05) whereas the monophasic pattern was prominent in group III (p?<?0.05).

Conclusion: The results demonstrate that as gestational age progresses, maximum flow velocities of both right hepatic vein and main portal veins intend to be decreased with an increased incidence of monophasic wave form pattern, and may be accepted as sensitive parameters of indicators of physiological adaptations related to pregnancy.     

Inherited long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency and a fetal-maternal interaction cause maternal liver disease and other pregnancy complications.

Fetal-maternal interactions are critical determinants of maternal health during pregnancy and perinatal outcome. This review explores the causative relationship of a fetal disorder of mitochondrial fatty acid oxidation, long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD) deficiency, and the serious maternal liver diseases of pregnancy-preeclampsia, the HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet counts), and acute fatty liver of pregnancy. Features of the metabolic adaptation necessitated during the fetal-neonatal transition; common phenotypes of pediatric fatty acid oxidation disorders, including neonatal hypoketotic, hypoglycemia and hepatic crisis; and clinical abnormalities of HELLP and acute fatty liver of pregnancy are presented. Evidence that a common mutation in the alpha-subunit (LCHAD) of trifunctional protein, E474Q, is always one of the mutant alleles in fetal isolated LCHAD deficiency associated with these disorders of pregnancy that cause high maternal, fetal, and newborn morbidity and mortality is reviewed. Recommendations for molecular testing for LCHAD deficiency in families with life-threatening maternal liver disease are given.     

Hepatic involvement in perinatal asphyxia.

BACKGROUND: The pathogenetic mechanisms of hepatic injury in perinatal asphyxia (PNA) are similar to those in ischemic hepatitis, yet liver involvement is currently not considered a component of multi-organ failure in PNA. METHODS: A retrospective study was done on 56 newborns with PNA. Hepatocyte injury was diagnosed based on elevated serum alanine transaminase level (>100 U/L, twice upper normal) with subsequent normalization. RESULTS AND CONCLUSIONS: Twenty-two of the patients had hepatocyte injury. Fetal distress, thrombocytopenia, convulsions, pathologic findings on imaging of the central nervous system, and a high rate of intrauterine growth retardation were the factors significantly associated with hepatocyte injury. This damage was also associated with high mortality.     

Extended resections for carcinoma of the colon and rectum

Eighty-four of 1,081 patients with carcinoma of the colon and rectum operated upon at our institution between 1951 and 1980 had extended resections involving adjacent organs. The types of presenting symptoms or the duration had no affect on the survival time of these patients. Survival time was most significantly correlated with pathologic penetration and Dukes' stage. The operative mortality was 5.9 per cent with a complication rate of 28.5 per cent. The nature of the individual organs involved did not affect the survival time. Patients with carcinoma of the colon and rectum extending to adjacent organs can undergo resection with a five year survival rate comparable with all patients with surgically treated carcinoma of the colon and rectum.     

Rsearch and other horizons in laparoscopy.

Accomplishments by laparoscopy and prediction of possible future development are reviewed. Some gynecological disorders can now be diagnosed at an early stage. Indications for laparotomy can be determined and postoperative assessments made. Improved safety factors have been introduced and methods of dealing with complications are described. In a case of uterine perforation at the time of aspiration abortion, fetal parts have been removed from the pelvis by laparoscopic technique. In 10 instances, appendectomy through a very small incision has been done under laparoscopic control. Intratubal devices have been placed for contraceptive purposes. This is a readily reversible procedure. In research studies, follicular growth and ovulation have been studied with human menopausal gonadotropin, human chorionic gonadotropin, and clomiphene administration. The levels of various steroids and prostaglandins in follicular fluid have been determined. More ovaries will be conserved. Diseased oviducts can be more accurately diagnosed and treated. Endometriomata will be better treated. With the new bioplar method and recently developed endothermic instruments, sterilization by coagulation will be safer. By using endothermal methods tubal and ovarian blood supply will be less injured. Teaching and textbooks will need to be revised. Other new fields of discovery and treatement promising valuable clinical application are anticipated.     

Hepatic resection in patients with cirrhosis and hepatocellular carcinoma.

Hepatic resection can be performed safely in carefully selected patients with cirrhosis. To minimize morbidity and mortality, it is essential to reliably estimate functional hepatic reserve and the extent of tumor before resection is performed. Child's classification is a reliable predictor of long term survival, but a more sensitive measure of hepatic function is needed to predict early morbidity and mortality. Child's classification can also be used to stratify patients and exclude those at high risk from hepatic resection. Promising predictors of operative mortality focus on the mitochondrial function of hepatocytes and include cytochrome a (+a3) contents and the redox tolerance index. Patients with advanced cirrhosis are not candidates for extensive hepatic resection and require careful evaluation before consideration for any hepatic resection. In patients with well-compensated cirrhosis and unifocal tumors, the procedure of choice is an anatomic resection of the tumor. If tumor size and location allows, a segmentectomy offers the best outcome, minimizing postoperative liver dysfunction while offering a long term outcome not dissimilar to a major liver resection. In highly selected patients with incidental tumors, a central tumor and perhaps in patients with multifocal hepatocellular carcinoma, hepatic transplantation may be of benefit. By using the appropriate predictors of hepatic function, refined surgical techniques and optimal postoperative care, a mortality rate of less than 10 per cent is achievable in cirrhotic patients with hepatocellular carcinoma who require resection.     

Pregnancies complicated by liver disease and liver dysfunction.

Although liver dysfunction is infrequently seen in pregnancy, it can result in severe maternal and fetal compromise. An unrecognized case of acute fatty liver may result in both maternal and fetal death. Failure to screen for hepatitis B can result in a newborn who will be a hepatitis carrier for life. Because of such consequences, the obstetrician must remain vigilant for signs of liver dysfunction and must understand the pathophysiology of these disorders.