Microwave endometrial ablation for menorrhagia.

Sixteen women requesting surgical treatment of menorrhagia were recruited for a study on microwave endometrial ablation. The mean age at treatment was 41.4 years and all patients had completed their family and were pre-menopausal. Average treatment time was 2 minutes 6 seconds. All patients reported a reduction in their menstrual loss and 87.5% were satisfied with their treatment after 1 year follow-up. One patient required overnight admission for analgesia while 15 patients were treated on a day case basis using light general anaesthesia. Sixty-seven per cent of patients reported a reduction in dysmenorrhoea scores at 1 year, two patients reported no change in symptoms and one patient reported a modest increase. One patient had a hysterectomy 10 months after treatment despite being amenorrhoeic. The indication for hysterectomy was pelvic pain (which was present before endometrial ablation). There were few minor complications but no uterine perforation or emergency hysterectomies.     

Intrauterine progesterone contraceptive system as an alternative in cases where conventional IUD's are unsuitable

A progesterone intrauterine device (IUD), Progestasert, was prescribed for 25 patients unable to use an ordinary non-hormonal IUD. Both the amount of menstrual bleeding and the discomfort was observed to decrease more often than increase during the period of use of the progesterone IUD. Hemoglobin, hematocrit and the serum iron levels either remained static or increased. Continuation rate was 76 per cent after one year. The authors consider Progestasert a suitable alternative to the ordinary non-hormonal IUD in women with dysmenorrhea or menorrhagia and those in whom a previous IUD had been associated with pain or increased menstruation.     

Evaluation of the surgical treatment of chronic calcifying pancreatitis

In the last 20 years, we have observed 264 instances of CCP. Of these, 136 (50.5 per cent) had 171 surgical procedures. Pancreatic calcifications were present in 83.1 per cent of the patients. One hundred and twenty-one were alcoholics (88.9 per cent) and 15 (11.0 per cent) abstained from alcohol. The surgical indications involved clinical uncontrollable pain and organic complications of the disease. The operations performed consisted of 62 wide side to side pancreaticojejunostomies, with loop excluded in Roux-en-Y, 40 pancreatectomies and 69 other operations. The choice of operation depended upon the analysis of each patient. The postoperative period of observation varied from two to 198 months, the average being 56.9 +/- 49.1 months. Thirty-five reoperations were performed for persistence or relapse of pain or the appearance of complications. Immediate post-operative complications and deaths occurred in 44 (25.7 per cent) and in six patients (3.5 per cent), respectively, considering the 71 operations performed. A satisfactory pain relief was evidenced in 61.0 per cent of the patients and total mortality reached 42.6 per cent. When the patients who underwent pancreaticojejunostomy, pancreatectomy and other operations were compared, no significant statistical difference was noticed with regard to the incidence of immediate post-operative complications and deaths, pain relief, appearance of diabetes or steatorrhea and mortality. There was also no significant difference as to the mortality among the alcoholic CCP, calcified or not, and idiopathic CCP (all calcified). On the other hand, the difference was statistically significant concerning the reoperation incidence in the group of patients who underwent the three types of operations mentioned. The longest survival time after pancreaticojejunostomy, pancreatectomy and other operations was 192, 137 and 198 months, respectively. The mean age at the time of death was 44.5 +/- 10.0 years, significantly inferior to the life expectation of the Brazilian male, which is 62 years. The mortality was higher in the first five postoperative years, corresponding to 77.6 per cent of the over-all mortality. There was no significant difference of survival time among the groups of patients undergoing the different types of operations. CCP is an extremely serious disease, progressive in spite of adequate treatment, sensibly diminishing the expectation and quality of lives of those with the condition, often interfering with the activity and productivity of the patient.(ABSTRACT TRUNCATED AT 400 WORDS)     

Carotid endarterectomy for chronic retinal ischemia

Carotid arterial disease may result in a variety of ischemic ocular problems that can eventually lead to permanent blindness. From 1984 to 1988, 18 patients underwent reconstruction of the carotid artery in an attempt to restore normal retinal arterial flow and, thereby, reverse or prevent progression of ischemic oculopathy. During a mean period of 21 months after carotid arterial reconstruction, subjective improvement in vision as well as a resolution in eye and periorbital pain was reported in 87.5 per cent of the patients. Measured visual acuity improved or stabilized in 94.4 per cent; macular photostress recovery times improved in 87.5 per cent, funduscopic examinations noted improvement or resolution in ischemic signs in 93.3 per cent and intraocular pressures improved in two of three patients. One patient experienced recurrent episodes of amaurosis fugax, which resolved after two weeks and did not recur. A second patient experienced an increase in intraocular pressures with visual deterioration, required laser photocoagulation after which the condition of the patient stabilized but only after significant visual impairment. Carotid arterial reconstruction is effective for the treatment of ischemic oculopathy and is most beneficial if performed early, before the onset of irreversible neovascular glaucoma.     

Menstrual, psychosexual, psychological and somatic sequelae following postpartum sterilisation.

This study was designed to investigate the menstrual, psychosexual, psychological and somatic sequelae in a group of women who may be more prone to express regret following sterilisation. They were at a younger age, and all underwent postpartum sterilisation. The follow-up was conducted by a questionnaire between 6 months and 5 years following the procedure. Data were available from 242 patients with 76.8% before age 30, and 23.2% age 30 or older. Of all the patients, 21.9% regretted their choice of sterilisation. About one-third had various menstrual cycle disturbances. In general, patients rated their sex life more enjoyable in many aspects. The two most common psychological symptoms were irritability, nervousness and depression. The common somatic symptoms were pelvic/ abdominal pain, backache and tiredness. A complete assessment of the patient's postoperative condition, including menstrual cycle history, sexual history, psychological and somatic complaints if any, is warranted during presterilisation counselling in addition to a routine informed consent. This is especially important for those patients who are known to be more prone to express regret following the procedure.     

A study of menstrual patterns following laparoscopic sterilization with silastic rings

The menstrual patterns of 281 women undergoing laparoscopic sterilization with silastic rings were studied prospectively. A significant increase in dysmenorrhea and irregular periods was seen soon after sterilization but this was transient, returning to presterilization levels by 12 months. Menorrhagia was not observed and the amount of menstrual blood loss showed a trend towards normal following sterilization. No permanent adverse effects on menstrual patterns were seen in the 1st year after sterilization. It is suggested that factors other than the sterilization procedure may be responsible for the high prevalence of menstrual dysfunction that has been reported following sterilization.     

Effect of acute pelvic inflammatory disease on fertility.

A total of 415 women treated for laparoscopically verified pelvic inflammatory disease (PID) were reviewed after 9.5 years. Of these, 88 (21.2 per cent) were involuntarily childless after one or more infection; in 72 cases (17.3 per cent) this was due to tubal obstruction; 263 (63.4 per cent) women became pregnant; 64 (15.4 per cent) were voluntarily childless. Tubal occlusion was diagnosed after one infection in 12.8 per cent, after two infections in 35.5 per cent, and after three or more infections in 75 per cent of the women. Tubal occlusion was more common after nongonorrheal than after gonorrheal salpingitis. Infertility varied with the inflammatory changes seen at laparoscopy. The ratio between ectopic and intrauterine pregnancies after the infections was 1/24. Chronic abdominal pain was reported by 18.1 per cent of the women. Corresponding findings in 100 healthy control subjects were: involuntary childlessness in three despite normal Fallopian tubes, one ectopic in 147 intrauterine pregnancies, and chronic abdominal pain in five cases.     

The significance of stable patients with sternal fractures

A retrospective review of patients admitted with sternal fractures without massive trauma to the chest or hypotension was undertaken. Chest pain was present in 59 of 60 patients while external signs of bruising were noted in one-third. The standard anteroposterior (AP) roentgenogram of the chest was diagnostic in all patients. Thirty-four (56.7 per cent) patients had 51 significant noncardiac injuries, an average of 1.5 injuries per patient. Most commonly, these were orthopedic injuries, fractures of the rib and closed head injuries. Sixty-two per cent of the patients with sternal fractures had abnormal electrocardiograms (ECG) at some time, of which 34 per cent had ECG changes consistent with ischemia. The admission ECG was normal in 20 (48 per cent) patients. Three of these patients subsequently had significant ECG changes. Fractures that were comminuted or involved the sternal angle were more likely to be associated with ECG abnormalities than were simple fractures of the sternal body. Only three patients had elevated creatine phosphokinase-myocardial bond fractions. Two dimensional echocardiography and biventricular radionuclide angiocardiography were normal in 11 patients, including five patients with ECG abnormalities. There were no deaths related to the sternal fractures per se or to associated injuries. Sternal fractures result from high energy trauma and should be suspected in patients with chest pain after blunt thoracic trauma. The lateral roentgenogram of the chest is the most useful diagnostic test. There is a high incidence of associated cardiac and noncardiac injuries in these patients mandating close observation with ECG monitoring in the intensive care unit.     

Surgical treatment of primary dysmenorrhea with laparoscopic uterine nerve ablation

With approximately 25% of dysmenorrheic patients reporting no improvement with nonsteroidal anti-inflammatory drugs, a study was devised to evaluate the effectiveness of a laparoscopic technique for the interruption of the uterosacral nerves. In a double-blind study of 21 patients with primary dysmenorrhea, 81% (9 of 11) reported significant relief from menstrual pain after the surgery. Performed as an outpatient procedure, laparoscopic uterine nerve ablation may alleviate dysmenorrheic complaints when other modalities have failed. Half the treated women reported continued relief of menstrual pain at 12 months. These results suggest that uterosacral nerve interruption may prove an effective alternative treatment for this menstrual disorder.     

Sequential administration of norethisterone and natural oral progesterone during premenopausal menstrual cycle disorders

A sequential treatment either with norethisterone or with oral natural micronized progesterone was administered, after randomization, to 80 women consulting for premenopausal disorders of the menstrual cycle. In all cases, the initial aspect of the endometrium showed a progesterone deficit with hyperplasia in 50 per cent of cases. At the third and sixth month of treatment, none of the biopsies presented hyperplastic characteristics whether after norethisterone or oral progesterone. However, three months after suspension of treatment, the proliferative or hyperplastic characteristics reappeared in 24 per cent of cases in the norethisterone group, and in 10 per cent of cases in the oral progesterone group. The administration of norethisterone induced a decrease in plasma levels of estradiol (E2), FSH and LH, and sex-hormone-binding globulin (SHBG) (p less than 0.001). No modification was observed during treatment with oral progesterone. The plasma levels of HDL-cholesterol and triglycerides were decreased by norethisterone (p less than 0.001-0.02). A slight decrease in phospholipids was also observed in this group. Treatment with oral natural micronized progesterone therefore offers an attractive alternative for the treatment of premenopausal menstrual disorders.     

Use of fallopian ring with laparoscopy for closure of oviduct (author's transl)

Reported in this paper is sterilisation by application of Fallopian ring with laparoscopy voluntarily undergone by 629 women. The amount of surgical complications (4.2 per cent) was found to be substantially affected by the surgeon's experience. There was one single case of pregnancy which could be considered as real failure of the method. The approach proved to be relatively dependable, easy to handle, and of little time consumption. It did not require long hospitalisation, and stress on the patients was minimal.     

Recurrent extra-uterine pregnancies. 63 cases treated at the Hospital Center of Libreville from 1985 to 1989]

Ectopic implantation of the fertilised ovum, whether for the first time or as a recurrence, is not uncommon in this department. In a study in the Libreville Hospital group from 1985 to 1989, the authors found 828 cases of ectopic pregnancy (EP) including 63 recurrences, i.e. 7.61 per cent. These recurrences most often involved young women (26 per cent of cases) and nullipara (30%). The chief common etiology for the first occurrence remained tubal infection (57.28 per cent of cases). Treatment consisted most often of radical macrosurgery because of the advanced state of tubal disease, thus leading to the permanent sterilisation of 48 patients, i.e. 71.2 per cent of recurrences. Nineteen patients had a history of previous conservative surgery, including 8 homolateral recurrences (43 per cent). Reducing the incidence of such pathology essentially involves the prevention of gynecological infections, and in particular sexually transmitted diseases, as well as the possibility of early diagnosis of EP. Despite the fact that it seriously compromises the subsequent fertility of these young patients, total salpingectomy remains the treatment of choice for avoiding recurrences.     

Trial of the calcium antagonist nifedipine in the treatment of primary dysmenorrhoea.

The effect of the calcium antagonist, nifedipine, on menstrual pain was investigated in 40 women with severe, primary dysmenorrhoea and 36 of them were observed over 3 consecutive menstrual cycles. Twenty-six patients experienced good pain relief, 10 moderate relief and 4 reported no benefit. The frequency of symptoms associated with menstrual pain was not reduced. Fifteen women regularly suffering from migraine during the menstrual period reported increased headache after intake of the drug. Due to this side effect four of these patients did not continue treatment for more than one cycle. All patients had transient facial flushing occurring 15--30 min after drug intake; this was well tolerated. An increase in pulse rate was also invariably found. However, only 5 patients complained of palpitations. Twenty-five of the 36 women completing the three-month trial wanted to continue nifedipine therapy regularly. It is concluded that calcium antagonists like nifedipine can be used for treatment of severe primary dysmenorrhoea, and that further evaluations of these drugs are indicated.     

The significance of galactorrhea in patients with normal menses, oligomenorrhea, and secondary amenorrhea

Thyroid-stimulating hormone and prolactin (PRL) were measured in a group of 149 women with galactorrhea. Three of these patients were found to have primary hypothyroidism. In the remaining 146 patients, the PRL assay was correlated with the menstrual history and the results of hypocycloidal polytomography. Sixty-two per cent of these patients had hyperprolactinemia and 35 per cent had abnormal tomograms. Nine patients with abnormal x-rays had normal prolactin levels. None of the patients with normal menses and normal PRL was found to have an abnormal x-ray. Fourteen of the 15 patients with PRL levels greater than 200 ng. per milliliter had abnormal tomograms. Almost 70 per cent of patients with secondary amenorrhea and low estrogen status had abnormal x-rays. In patients with oligomenorrhea and secondary amenorrhea with normal estrogen status, it was not possible to differentiate between patients with normal or abnormal tomograms based on the level of serum PRL. Polytomography remains the single most important diagnostic test in establishing the presence of a pituitary tumor.     

Accidental splenic injury during surgical treatment of the colon and rectum

Although operative injury to the spleen continues to account for a large number of splenectomies, the incidence of injury during operations upon the colon and rectum has not previously been reported. Of 993 consecutive colonic and rectal excisions, the spleen was injured in eight and splenectomy resulted in three. Two hundred and sixty patients had the splenic flexure of the colon mobilized. All splenic injuries occurred in this group (3.1 per cent) for an incidence of splenectomy during splenic flexure mobilization of 1.15 per cent. In all patients, splenic injury consisted of a capsular tear and was a result of traction on spleno-omental peritoneal bands in 50 per cent. The spleen was salvaged using topical hemostatic agents in 63 per cent of the injuries. A method of splenic flexure mobilization which improves visualization of splenic attachments and avoids traction injuries is discussed. The morbidity and mortality from traumatic splenectomy are also reviewed.     

Effect of various factors on in vitro fertilization (IVF) and embryo transfer in the human in clomiphene/hMG/hCG stimulated cycles

In the present study we tried to analyse data obtained on the occasion of an in vitro fertilization programme at the department of obstetrics and gynecology of the University of Kiel, to extract some of the important factors, because their positive or negative influence on the success of extracorporal insemination, embryo transfer and implantation has not been clearely defined till now and to value their concern. Between July 1982 and February 1983 105 sterile patients with ovulatory menstrual cycles have been treated by the technique of in vitro fertilization and embryo transfer, successively. Follicular growth was stimulated by 150 mg clomiphen daily from 3rd to 7th day and application of 225 IU hMG on 6th, 8th and 10th day. Finally ovulation was timed 36 hours before follicular puncture by 5000 IU hCG. In 24 per cent endogenous LH peak could be observed. In 86 per cent of the 80 patients exactly timed one oocyte was to be found minimally. In 68 per cent of these patients after all an embryo transfer was done (24 times one embryo, 13 times two, 9 times three and once four embryos). 89% of the embryos have been transfered as 4-or 8-cell stage, only 11 per cent as two cell stage. Transfer took place 48 to 50 hours following insemination. There was no correlation between the maturity classified morphologically of the oocytes and the diameter of their follicles. The speed of development of the embryos was not correlated with the size of their follicles. too. In 60-70 per cent of all cases, in which an embryo transfer was possible, husbands had normal spermiogram. The percentage of unfertilised oocytes following insemination using non-optimal sperma was increased in all types of cycles, additionally there was a reduction of the developing speed of resulting embryos. Doubtless two the four pregnancies resulted after insemination using sperma of less quality. The conjugation rate is said to be not correlated directly with the exactness of timing of the application of hCG with reference to follicular maturity, but in all pregnancies hCG was injected simultaneously with the peak of estradiol.     

Surgical treatment for carcinoma of the esophagus in the elderly patient

There were 250 Japanese patients with carcinoma of the thoracic esophagus who had been admitted to the Second Department of Surgery at the Kyushu University Hospital from 1972 to 1982. Resection for carcinoma of the esophagus was performed upon 160 of these patients (64 per cent). These 160 patients were classified into three groups according to age, and preoperative examination, postoperative complications, mortality and late results were reported. In patients more than 70 years old, the incidence of abnormal findings at preoperative examination was high with a statistical difference and the incidence of postoperative complications was also high in elderly patients. Although the over-all mortality within one month after operation was seen in eight of 160 patients (5 per cent) surgically treated, the rate was 12.8 per cent when confined to those patients more than 70 years old. Thus, the indication for surgical treatment should be carefully determined for elderly patients with carcinoma of the esophagus. If the elderly patient can tolerate the surgical procedure, the five year survival rate is equal to that of younger patients. Since there is an increase in people more than 70 years old, the surgeon must be prepared for the challenge of treating elderly patients with carcinoma of the esophagus.     

Cholecystokinin enhanced hepatobiliary scanning with ejection fraction calculation as an indicator of disease of the gallbladder

Chronic acalculous cholecystitis represents 5 to 20 per cent of electively treated diseases of the gallbladder. A 70 per cent success rate in relieving these patients of chronic pain was reported when surgical treatment was recommended based on symptoms alone. The cholecystokinin ejection fraction, which is a quantitative measure of emptying of the gallbladder, was 95 per cent accurate in predicting which patients would be relieved of symptoms by surgical treatment. In this study, we report our consecutive experience during a 20 month period with 83 patients.     

Heller-Belsey and Heller-Nissen operations for achalasia of the esophagus

From 1972 to 1985, 101 consecutive patients underwent Heller's myotomy and Belsey repair (H + B) (n = 43) or Nissen fundoplication (H + N) (n = 58) for achalasia of the esophagus. There was no operative mortality after either operation; minor pulmonary complications occurred after H + B procedure in 9.3 per cent of the patients. Good to excellent long term results were achieved in 87 per cent of the patients after H + B repair and 83 per cent of the patients undergoing H + N. The failure rates were 2.5 and 11.3 per cent, respectively. The analyses of postoperative esophageal symptoms showed that the incidence of heartburn was greater after H + B repair and the incidence of obstructive symptoms was greater after H + N. The inability to vomit or belch, or both, was 10.2 per cent in the H + B group and 13.1 per cent in the H + N group. Finally, 56.4 per cent of patients after H + B repair and 41.0 per cent of those after myotomy and H + N were considered to be cured after the operative procedure was performed. Patients were improved in 41.0 and 47.3 per cent, respectively.     

A comparison of blood calcium levels between and during menstrual periods

Recently¹ we presented a preliminary paper on the use of parathyroid hormone in the control of idiopathic menstrual bleeding. Continuing this work we found it necessary to obtain a basis for comparison of plasma calcium levels in normal women. These results form the basis for this report.It seemed quite logical to assume that the menstrual period should cause a rise in the blood calcium since various investigators^{2, 3, 4, 14} report an elevation during pregnancy or lactation in women and during estrus in animals.There are many reports, beginning with the work of Bell⁵ in 1909, that record a rise in blood calcium at menstrual time. The results obtained by Shorlit et al.⁶ seemed to indicate that the blood calcium rises just preceding the onset of the menstrual period. Watchorn⁷ reports an increase of serum magnesium in a menstrual period associated with pain but no change in the blood calcium. Rittmann⁸ in his series reports a calcium variation in 83 per cent of cases.Determinations of the blood calcium in practically all of these reports were made on specimens of blood drawn at various times throughout the monthly cycle and particularly during the menstrual flow.