Piperacillin/tazobactam-induced sudden severe thrombocytopenia in a patient with a pressure ulcer: a case report.

The standard treatment for an infected pressure ulcer (PU) with osteomyelitis is debridement, wound coverage and antibiotic administration. However, systemic administration of antibiotics in patients with osteomyelitis is controversial, and the optimal treatment duration for chronic osteomyelitis has not been standardised. We report a case of sudden severe thrombocytopenia induced by piperacillin/tazobactam (PIPC/TAZ) in a patient with PU-related osteomyelitis. A 57-year-old male patient with paraplegia, using a wheelchair full-time, presented to our plastic surgery department with infection of a stage IV hard-to-heal ischial PU. We surgically debrided the necrotising tissue and raised an ipsilateral biceps femoris musculocutaneous propeller flap for wound coverage. Polymicrobial infections, including Pseudomonas aeruginosa, were detected in the bone biopsy sample; therefore, systemic PIPC/TAZ was administered for the osteomyelitis. Unexpectedly, during the next 12 days of antibiotic administration, the patient's platelet count acutely dropped to 1×103/µl over three days. Based on a series of examinations, PIPC/TAZ was suspected to be the most likely cause of the severe thrombocytopenia. After drug discontinuation, the thrombocytopenia gradually improved. PIPC/TAZ is one of the most widely used antibiotic combinations in the plastic surgery field; it is conventionally administered for hard-to-heal wounds such as PUs and diabetic foot. The present case suggests that surgeons must take special precautions for patients undergoing PIPC/TAZ treatment. In this report, PIPC/TAZ-induced thrombocytopenia and the efficacy of antibiotic treatment for PU-related osteomyelitis are discussed in light of the available literature.

Denonvilliers' fascia as a potential nerve-course marker for the female urinary bladder.

OBJECTIVES: This study investigated the relationship between Denonvilliers' fascia (DF) and the pelvic plexus branches in women and explored the possibility of using the DF as a positional marker in nerve-sparing radical hysterectomy (RH). METHODS: This study included eight female cadavers. The DF, its lateral border, and the pelvic autonomic nerves running lateral to the DF were dissected and examined. The pelvis was cut into two along the mid-sagittal line. The uterine artery, deep uterine veins, vesical veins, and nerve branches to the pelvic organs were carefully dissected. RESULTS: The nerves ran sagitally, while the DF ran perpendicularly to them. The rectovaginal ligament was continuous with the DF, forming a single structure. The DF attached perpendicularly and seamlessly to the pelvic plexus. The pelvic plexus branches were classified into a ventral part branching to the bladder, uterus, and upper vagina and a dorsal part branching to the lower vagina and rectum as well as into four courses. Nerves were attached to the rectovaginal ligament and ran on its surface to the bladder ventral to the DF. The uterine branches split from the common trunk of these nerves. The most dorsal branch to the bladder primarily had a common trunk with the uterine branch, which is the most important and should be preserved in nerve-sparing Okabayashi RH. CONCLUSION: The DF can be used as a marker for nerve course, particularly in one of the bladder branches running directly superior to the DF, which can be preserved in nerve-sparing Okabayashi RH.

Why don't we follow influencers in obstetrics and gynaecology on Twitter to obtain information on the most recent international congresses?

We proposed following influencers in obstetrics and gynecology on Twitter. We believe that the use of Twitter may help obstetrics and gynecology doctors in low-income countries as well as stimulate fellows and residents by following actual discussions at international conferences.

Improved bladder function in radical hysterectomy without worsening oncologic outcome: resection of the posterior layer of the vesicouterine ligament with the procedure limited to the vesical veins.

OBJECTIVE: The classic Okabayashi nerve-sparing radical hysterectomy involves complete resection of the posterior leaf of the vesicouterine ligament, whereas in the simplified nerve-sparing radical hysterectomy, only the vesical veins and some connective tissue of the posterior layer of the vesicouterine ligament are resected. This study aimed to compare bladder function and cervical carcinoma relapse-free survival between these two techniques. METHODS: We conducted a retrospective, historical control study. All female patients aged >20 years who were diagnosed with cervical cancer stage IB1-IIB and underwent radical hysterectomy with pelvic lymphadenectomy between 2009 and 2022 were enrolled. Patients who had a history of other cancers and those who were treated with non-surgical approaches or non-radical hysterectomy were excluded. The primary outcome was relapse-free survival during the follow-up period. RESULTS: A total of 114 patients who underwent curative-intent radical hysterectomy were included in this study. The median follow-up duration was 60 months. No significant difference was observed in relapse-free survival between the two surgical procedures. The simplified nerve-sparing radical hysterectomy was superior in terms of both motor and sensory bladder function outcomes. CONCLUSION: Resection of the posterior layer of the vesicouterine ligament, with the procedure limited to the vesical veins, is an effective and safe method for radical hysterectomy. It may be more useful for preserving the bladder function, without leading to unfavorable oncologic outcomes.

Volume Index Measured Using Magnetic Resonance Imaging for Diagnosing Cervical Cancer Tumors <2 cm.

BACKGROUND/AIM: Diagnosis of cervical cancer with tumor diameter <2 cm using magnetic resonance imaging alone has not been investigated. Moreover, whether tumor volume can be used for diagnosing the true tumor diameter remains unknown. Here, we investigated the utility of early cervical cancer volume index in diagnosing cervical cancer with a tumor diameter of <2 cm, which can be treated using more conservative surgery. PATIENTS AND METHODS: This single-center retrospective study analyzed women who underwent radical hysterectomy for cervical cancer with a tumor diameter of <2 cm and clinical stages IA2, IB1, IB2, IB3, and IIA1 at our institute between January 2009 and April 2022. The volume index, defined as the product of the maximum longitudinal diameter along the uterine axis, maximum anteroposterior diameter (thickness) on a sagittal section image, and maximum horizontal diameter on a horizontal section image, was evaluated using either T2-weighted magnetic resonance imaging or gadolinium-enhanced T1-weighted imaging. The receiver operating characteristic curve for the volume index was also calculated. RESULTS: The sensitivity and specificity of magnetic resonance imaging for measuring the tumor diameter were 0.92 and 0.84, respectively. The calculated cut-off value was 2.60, whereas the volume index area under the curve was 0.955, with a sensitivity of 0.92 and specificity of 0.93. CONCLUSION: Considering the specificity and low incidence of false-negative results, the volume index can be used for preoperative diagnosis of pT1B1 cervical cancer, which can be treated with more conservative surgery.

Risk Factors Associated with Perineal and Vaginal Lacerations and Vaginal Removal in Total Laparoscopic Hysterectomy.

Objectives: This study aimed to identify risk factors associated with perineal and vaginal lacerations related to vaginal removal during total laparoscopic hysterectomy (TLH). Materials and Methods: We retrospectively assessed 134 patients who underwent TLH, of whom 44 (32.8%) had vaginal lacerations. Results: Univariate analysis revealed that for patients with myomas and adenomyosis, gonadotropin-releasing hormone agonist use and myomas with a transverse diameter of ≥5 cm were significant risk factors, while multiparity (vaginal delivery) was a protective factor for perineal and vaginal lacerations. Moreover, multivariate analysis indicated that multiparity was the only statistically significant protective factor. For cervical intraepithelial neoplasia, endometrial cancer, and endometrial hyperplasia, only a uterine transverse diameter of ≥5 cm was a significant risk factor for perineal or vaginal lacerations. Conclusion: For patients with large myomas, multiple vaginal delivery was a protective factor, and in patients with normal-sized uteri, a uterine transverse diameter of ≥5 cm was a risk factor for perineal or vaginal lacerations.

Volume Index is a Risk Factor for Recurrence Even in Patients with Clinical Stage IA Endometrial Cancer Undergoing either Laparotomy or Laparoscopy: A Retrospective Study.

Objectives: The objective of the study was to investigate the long-term outcomes, in particular, recurrence risk, especially tumor volume, for Stage IA endometrial cancer and to identify the risk factors for recurrence. Materials and Methods: This single-center retrospective study analyzed women who underwent primary surgical treatment for the International Federation of Gynecology and Obstetrics Stage IA (Grade 1 or 2) endometrioid carcinoma at our institute between January 2010 and July 2018. Patients' demographic characteristics, including age, operative time, number of lymph nodes, final stage, volume index as tumor volume, and final histological type, were reviewed. A total of 168 patients were enrolled, with 95 and 73 patients in the laparotomy and laparoscopy groups, respectively. The Cox proportional hazards model was used to adjust for prognostic factors in the analysis including upstaged patients, tumor histology, lymphovascular invasion, and volume index. Results: There was no difference in the recurrence rate between laparoscopic and open surgeries for Stage IA endometrial cancer. The operative time was longer, and the amount of blood loss was lesser in the laparoscopy group than in the laparotomy group. For all patients undergoing either laparoscopy or open surgery, upstaged ≥IB, nonendometrioid Grade 1 or 2, lymphovascular invasion, and volume index ≥36 were significant independent recurrence risk factors. Conclusion: Laparoscopic surgery for Stage IA endometrial cancer is technically and oncologically safe. Patients with a high-volume index have a higher recurrence risk. Furthermore, the volume index can be a recurrence predictor in low-risk endometrial cancer patients.

Assessing the Effectiveness of a Weight Reduction Program in Hospitalized Obese Patients Undergoing Laparoscopic Surgery.

Investigate the efficacy of a hospitalized weight reduction program before laparoscopic surgery among high body mass index (BMI) patients with endometrial cancer. The patients were housed in a shared room, received exercise guidance, and restricted to a total caloric intake of 1200 kcal. A physiotherapist and a dietitian provided pedometer and nutritional guidance, respectively. The primary outcome was weight reduction. Among the 16 patients included, 12 (75%) had Stage I endometrial cancer and 10 (62.5%) underwent laparoscopic surgery. Weight and BMI at first consultation were 88.4±10.4 kg and 34.8±3.9 kg/m2, respectively. The rate of weight reduction was 6.5%±2.5%; on average, BMI decreased by 2.1±1.0 kg/m2. The duration from initial consultation to surgery was 39.1±11.4 days. Hospitalization duration until weight reduction was 20.8±8.0 days; there were no surgical complications. Our hospitalized weight reduction program may be effective for obese endometrial cancer patients.

A cystectomic technique with low risk of rupture for women with benign ovarian cyst.

The majority of patients with benign ovarian cysts undergo laparoscopic surgery using both cystectomy and stripping techniques. However, these techniques have difficulty correctly identifying cleavage planes and are prone to cyst rupture. We present a surgical cystectomy technique that correctly identifies the cleavage plane with a low risk of ovarian cyst rupture, even in patients with multicystic ovarian cysts. Cystectomy was performed using Maryland forceps with gentle open and close dissecting motions only. Both the surgeon and assistant handled the ovarian cortex and cyst wall, and soft traction between the cortex and cyst wall as far as the nearby dissection plane without grasping the cyst wall was essential. In patients with multicystic ovarian cysts, making a plane at the notch between cysts decreases the risk of cyst rupture. This technique allows the correct identification of the cleavage plane for dissection and avoids the risk of cyst rupture.Impact StatementWhat is already known on this subject? The majority of patients with benign ovarian cysts undergo laparoscopic surgery using both cystectomy and stripping techniques. These techniques have difficulty correctly identifying cleavage planes and are prone to cyst rupture.What do the results of this study add? This technique allows the correct identification of the cleavage plane for dissection and avoids the risk of cyst rupture.What are the implications of these findings for clinical practice and/or further research? Our technique might be useful for the preservation of the ovarian reserve because patients in this study had a low proportion of ovarian follicles in the surgical specimen.

Pegfilgrastim Maintains Relative Dose Intensity and Decreases Hospitalisations in Patients With Endometrial Cancer.

BACKGROUND/AIM: Data are limited regarding the use of pegfilgrastim in gynaecologic oncology. We evaluated its efficacy for maintaining dose intensity during chemotherapy. PATIENTS AND METHODS: We retrospectively examined the data of 65 women (26 pegfilgrastim users) who underwent primary surgical treatment for stages IB-IV endometrial cancer and had adjuvant chemotherapy containing platinum and taxane; the primary outcome was a relative dose intensity ≥85%. RESULTS: In the pegfilgrastim vs. the control group, body mass index (26.6±5.9 vs. 23.4±4.4), rate of relative dose intensity ≥85% (88.5% vs. 15.4%), plus other adverse event incidences were significantly higher; rate of neutropenia, total hospital visits during chemotherapy (11.0±2.1 vs. 18±5.6 days), unscheduled hospital visits (1.1±1.8 vs. 5.8±5.1 days), and unscheduled granulocyte colony-stimulating factor injections (0.58±1.7 vs. 6.4±5.1 days) were significantly lower. CONCLUSION: Pegfilgrastim can maintain a dose intensity of ≥85% during chemotherapy for the treatment of gynaecologic cancers and decrease hospital-visit frequency.

Lymphatic Malformation Treated with Lymphatic Malformation-Venous Anastomosis Under Local Anesthesia.

Lymphatic malformation (LM) can occur in the head and neck regions and cause cosmetic problems in adults. Sclerotherapy and surgical resection have been frequently applied; however, both are far from being minimally invasive in terms of aesthetic satisfaction, including the aesthetic downtime. We performed a less-invasive treatment using the venous anastomosis technique, named the lymphatic malformation-venous anastomosis (LMVA), mainly in pediatric patients with intractable microcystic lesions, in whom general anesthesia was required because the pediatric patients could not remain still. Here, we report the case of a 35-year-old man with a cystic submandibular LM successfully treated with LMVA under local anesthesia. He presented with a gradually enlarging LM on the neck. For improving aesthetics, LMVA was planned under local anesthesia. Lymphography by injecting indocyanine green revealed no inflow or outflow connection to the malformation; thus, we created an outflow bypass using the sidewall of the LMVA technique. The patient was discharged on the following day of the operation without any postoperative complications. A volumetric analysis 6 months later showed a 43.5% reduction of the malformation, with the patient being completely satisfied with the result. To the best of our knowledge, there has been no previous report on performing LMVA under local anesthesia in an adult. LMVA can be a novel treatment of choice when other options are less feasible.