Using amniotic membrane for anal sphincter repair in animal model / Uso de membrana amniótica para reparo de esfíncter anal em modelo animal

Purpose: Sphincter repair is the primary management for fecal incontinence especially in traumatic causes. Regardless of progression in the method and material of sphincter repair, the results are still disappointing. This study evaluates the efficacy of using amniotic membrane during sphincteroplasty regarding its effects in healing of various tissues. Methods: Rabbits undergone sphincterotomy and after three weeks end to end sphincteroplasty was done. Animals divided to three groups: classic sphincteroplasty, sphincteroplasty with fresh amniotic membrane and sphincteroplasty with decellularized amniotic membrane. Three weeks after sphincteroplasty animals were sacrificed and sphincter complex was sent for histopathologic evaluation. Sphincter muscle diameter and composition of sphincter was evaluated. Before sphincterotomy, before and after sphincteroplasty electromyography of sphincter at the site of repair were recorded. Results: No statistical significant difference was seen between groups even in histopathology or electromyography. Conclusion: Although amniotic showed promising effects in the healing of different tissue in animal and human studies it was not effective in healing of injured sphincter.

Objetivo: Reparo do esfíncter é o tratamento primário para casos de incontinência fecal, especialmente em causas traumáticas. Independentemente da progressão no método e do material de reparo do esfíncter, os resultados são ainda desapontadores. Esse estudo avalia a eficácia do uso da membrana amniótica durante a esfincteroplastia, com relação aos seus efeitos na cura de diversos tecidos. Métodos: Coelhos foram submetidos a um procedimento de esfincterotomia e, depois de transcorridas três semanas, foi realizada uma esfincteroplastia término-terminal. Os animais foram divididos em três grupos: esfincteroplastia clássica, esfincteroplastia com membrana amniótica fresca, e esfincteroplastia com membrana amniótica descelularizada. Três semanas após a realização da esfincteroplastia, os animais foram sacrificados e o complexo esfinctérico foi encaminhado para avaliação histopatológica. O diâmetro do músculo esfinctérico e a composição do esfíncter foram avaliados. Antes da esfincterotomia, e antes e depois da esfincteroplastia, foi registrada a eletromiografia do esfíncter no local do reparo. Resultados: Não foi observada diferença estatisticamente significativa entre os grupos, mesmo na histopatologia, ou na eletromiografia. Conclusão: Embora a membrana amniótica tenha demonstrado efeitos promissores em termos da cicatrização dos diferentes tecidos em estudos com animais e em humanos, não foi observada eficácia na cura do esfíncter lesionado.

Análise crítica dos métodos não-farmacológicos de indução do trabalho de parto / Critical analysis of non-pharmacological methods for induction of labor

A indução do trabalho de parto tem se tornado prática corrente na Obstetrícia moderna. Vários métodos têm sido propostos, e dentre eles os não-farmacológicos merecem destaque. Estes métodos podem ser classificados como naturais e artificiais. Os estudos realizados para avaliar os diversos métodos naturais, como homeopatia, acupuntura, óleo de rícino, enema, banho quente de imersão, relações sexuais e estimulação mamária para indução do trabalho de parto, são heterogêneos e ainda não existe evidência suficiente de que possam ser utilizados na prática clínica. Dentre os métodos artificiais, o descolamento das membranas encontra-se associado à indução efetiva do parto, porém, o procedimento é doloroso e pode ser desconfortável para as mulheres. A capacidade máxima de dilatação da laminária ocorre entre 12 e 24 horas, entretanto tem sido pouco utilizada devido ao surgimento de métodos mais efetivos. A sonda de Foley constitui um procedimento efetivo que pode ser usado na presença de contraindicações para os métodos farmacológicos, especialmente em gestantes com cesárea anterior, porém persistem preocupações quanto ao risco de infecção materna e fetal. Por outro lado, a ruptura artificial das membranas e os métodos mecânicos ainda não podem ser recomendados, porque as evidências sobre sua efetividade e segurança são insuficientes, mesmo quando associados à administração intravenosa de ocitocina.

Induction of labor has been currently a routine practice in Obstetrics. Several methods have been proposed and among them the non-pharmacological methods deserve consideration. These methods are classified as natural and artificial ones. Studies conducted to evaluate natural methods, such as homeopathy, acupuncture, ricin oil, enema, hot water immersion, sexual intercourse and nipple stimulation for labor induction, are heterogeneous and there is no enough evidence yet to support their use in clinical practice. Among artificial methods, membrane sweeping is associated with success on labor induction but can be a painful procedure, which is considered uncomfortable by several women. The maximum dilation of laminaria occurs between 12 and 24 hours, but this method has been less used because other methods are more effective. Foley catheter is a safe and effective procedure that can be used in the presence of contraindications for pharmacological methods, especially in pregnant women with previous cesarean section. Notwithstanding, there are still concerns about the risk of maternal/fetal infection. On the other hand, artificial rupture of membranes (amniotomy) cannot be recommended so far because evidences about its effectiveness and safety are insufficient, even when associated with intravenous administration of oxytocin.

Vaginoplasty by using amnion graft in patients of vaginal agenesis associated with Mayor-Rokitansky-Kuster-Hauser Syndrome

Vaginal agenesis is congenital anomaly of the female genital tract and may occur as isolated developmental defect or as part of a complex of anomalies. The aim of this study was to determine the effectiveness of vaginoplasty by using amnion as graft in the creation of neovagina for patients with Mayor-Rokitansky-Kuster-Hauser Syndrome. This is a retrospective study of 28 cases of vaginal agenesis associated with Mayor-Rokitansky-Kuster-Hauser Syndrome, over the period of 20 years, in which vaginoplasty was done by modified McIndoe procedure by using amnion as graft. Vaginoplasty using amnion graft was successfully performed in all except one case in which rectum got opened and procedure was abandoned after the repair of rectum. The functional results were quite satisfactory. Except one case none had any significant peri-operative complication. Post surgical results were acceptable to the patients sexually and aesthetically. Although new techniques of vaginoplasty have evolved over the years using laparoscopic approach and by use of different materials as graft, vaginoplasty with amnion graft is still a safe and effective procedure to treat patients of vaginal agenesis. The technique is simple and safe and provides a satisfactory and functional vagina in majority of the patients

Membrana amniótica canina utilizada como bandagem em úlcera superficial de córnea de coelhos: aspectos clínicos / Canine amniotic membrane used as a bandage on rabbit superficial corneal ulceration: clinical aspects

Realizou-se a ceratectomia superficial em 28 coelhos, distribuídos em dois grupos. No grupo tratado, composto por 14 animais, utilizou-se a membrana amniótica canina como bandagem, suturada com sua face epitelial voltada contra a superfície corneana. O grupo controle não recebeu tratamento. A avaliação clínica foi realizada 24 horas após a cirurgia, a cada dois dias durante uma semana e a cada quatro dias até 180 dias. Avaliaram-se os efeitos da membrana amniótica como bandagem, comparando-se o tempo de epitelização da córnea entre os grupos e verificando o período necessário para que a córnea apresentasse transparência completa. A opacidade corneana esteve presente em todos os animais durante o período observado. O tratamento instituído resultou clinicamente em neovascularização corneana, opacidade de córnea mais intensa no período inicial de reparação, retardou o processo de epitelização e causou mais dor e desconforto que nos animais do grupo-controle.

Twenty-eight rabbits were submitted to superficial keratectomy. The treated group consisted of 14 animals received canine amniotic membrane as a bandage, sutured in a way that its epithelial surface was in contact with the corneal surface. The control group did not receive any treatment. The animals were submitted to clinical evaluations 24 hours after surgery, at each two-day interval during one week and at each four-day interval during 180 days. The amniotic membranes were evaluated as a bandage comparing the time needed for corneal epithelization in the treated and non-treated groups and determining the period necessary for the cornea to become completely transparent. The corneal opacity was present during the entire time of observation. The treated animals presented more opaque cornea in the early period of regeneration, with neovascularization and more pain and discomfort than the animals from control group, showing a delayed epithelization.

Cauterización de la membrana de Bowman y el injerto de membrana amniótica en la queratopatía bullosa dolorosa poscirugía de catarata / Cauterization of Bowman´s membrana and amniotic membrane graft in painful bullous keratopathy after cataract surgery

Introducción: La queratectomía con cauterización de la membrana de Bowman y el injerto de membrana amniótica son algunos de los tratamientos paliativos en pacientes con queratopatía bullosa dolorosa sin criterio de trasplante corneal. Describir los resultados de cada una de estas técnicas fue nuestro objetivo fundamental en este estudio. Métodos: Se realizó un estudio descriptivo con 34 pacientes con queratopatía bullosa dolorosa poscirugía de catarata. Se distribuyeron en dos grupos: queratectomía con cauterización de la membrana de Bowman y queratectomía con injerto de membrana amniótica con seguimiento por seis meses. Resultados: A los seis meses se mantenían sin bulas 64,7 y 41,2 por ciento de los casos con cauterización de la membrana de Bowman e injerto de membrana amniótica respectivamente. El incremento de la vascularización corneal fue mínimo para ambas técnicas quirúrgicas. Se logró el alivio de los síntomas en la primera semana de la cirugía para 82,4 por ciento en la cauterización de la membrana de Bowman y 94,1 por ciento en el injerto de membrana amniótica. A los seis meses de la cirugía se mantenían asintomáticos 88,2 y 70,6 por ciento de los casos con cauterización de la membrana de Bowman e injerto de membrana amniótica, respectivamente. La epitelización corneal se produjo antes de los 14 días en el 100 por ciento de los pacientes tratados con injerto de membrana amniótica y en el 94,1 por ciento de los pacientes con cauterización de la membrana de Bowman. Conclusiones: Ambas técnicas quirúrgicas fueron eficaces en el tratamiento a corto plazo de la queratopatía bullosa dolorosa poscirugía de catarata.

Introduction: Keratectomy with cauterization of Bowman´s membrane and the amniotic membrane graft are some of the palliative therapies to be applied in patients with painful bullous keratopathy without any criterion of corneal transplant. To describe the results of each technique was our fundamental objective in this study. Methods: A descriptive study of 34 patients with painful bullous keratopathy after cataract surgery was carried out. They were divided into two groups: one undergoing keratectomy with cauterization of Bowman´s membrane and the other amniotic membrane graft followed-up for six months. Results: After six months, 64.7 percent of cases with cauterization of Bowman´s membrane and 41.2 percent of those with amniotic membrane graft had no blebs. Increase of corneal vascularization as minimal for both techniques. The symptom relief in the first week of surgery was observed in 82.4 percent and 94.1 percent of cases respectively. After six months, the patients kept asymptomatic in 88.2 percent of cases with cauterized Bowman´s membrane and 70.6 percent of amniotic membrane grafts. Corneal epithelization occurred before 14 days of surgery in 100 percent of patients treated with graft and in 94.1 percent of cauterized cases. Conclusions: Both surgical techniques are effective in short-term treatment of painful bullous keratopathy after a cataract surgery.

Autoinjerto conjuntival versus injerto de membrana amniótica en la cirugía del pterigión primario / Conjuctival autograft versus amniotic membrana graft in primary pterygium surgery

Introducción: El pterigión es una de las afecciones oftalmológicas más frecuentes en el mundo. Teniendo en cuenta que actualmente la prevención de la recidiva en el pterigión constituye un reto importante para los oftalmólogos, se decidió realizar un estudio para comparar la eficacia del autoinjerto conjuntival con células límbicas y el injerto de membrana amniótica. Métodos: Se realizó un estudio prospectivo comparativo, cuya muestra estuvo compuesta por 45 ojos de 30 pacientes tratados con excéresis seguida de injerto de membrana amniótica, y 45 ojos de 30 pacientes quienes recibieron autoinjerto conjuntival. El seguimiento posoperatorio se realizó hasta los 12 meses de la cirugía. Resultados: En el grupo al que se le realizó autoinjerto conjuntival, 2 pacientes (4,4 por ciento) desarrollaron inflamación del injerto, de los cuales un caso (2,2 por ciento) evolucionó a un granuloma. Uno de ellos (2,2 por ciento) presentó recidiva del pterigión. En el grupo de injerto de membrana amniótica, 3 casos (6,6 por ciento) recidivaron. El porcentaje de recidiva fue bajo para ambos grupos; pero fue más efectivo el autoinjerto conjuntival con células límbicas. Conclusiones: La complicación más importante fue la recidiva del pterigión. El autoinjerto de conjuntiva fue más efectivo que el injerto de membrana amniótica.

Introduction: Pterygium is a common eye disease worldwide. Preventing recurrence is an important challenge for the ophthalmologic surgeons at present, so it was decided to perform a study in order to compare the efficacy of conjuctival autograft with limbic cells with that of the amniotic membrane graft. Methods: A prospective comparative study was made on 45 eyes from 30 patients treated with exeresis followed by amniotic membrane graft, and 45 eyes from 30 patients who were performed conjunctival autograft. The postoperative follow-up lasted 12 months after the surgery. Results: There were two cases (4.4 percent) with autograft inflammation in the conjunctival autograft group and and one of them (2.2 percent) developed granuloma. Also one presented with pterygium recurrence. In the amniotic membrane graft group there were three recurrences (6.6 percent). The recurrence percentage was low in both groups, but conjunctival autograft with limbic cells was more effective. Conclusions: The most important complication was pterygium recurrence. The conjunctival autograft was more effective than the amniotic membrane graft.

[Comparison of early versus late amniotomy following cervical ripening with foley catheter]

Amniotomy is usually used for induction or augmentation of labor and if timely applied it could influence the labor promotion. The aim of the present study was to evaluate the time of amniotomy on labor course. This prospective randomized clinical trial was carried out at Kosar Hospital affiliated to Qazvin University of Medical Sciences [Iran] in 2005. Nulliparous women 40 weeks of a singleton gestation, cephalic presentation, intact membrane, and cervical dilatation 1cm were selected. All women underwent cervical ripening using a foley catheter. Following spontaneously removal of the catheter, women were randomly assigned to either early or late amniotomy. While in first group amniotomy was performed immediately, it was carried out in second group at active phase following the beginning of oxytocin infusion. Duration of labor, cesarean section rate and indications, and Apgar score at 5 minutes in two groups were recorded. Data were analyzed using statistical tools including t test and chi square test. Duration of labor from the time of catheter removal to delivery in early amniotomy was longer than that of late amniotomy [12 hours and 40 minutes versus 9 hours and 40 minutes, [P=0.35]]. The rate of cesarean section was shown to be higher in early amniotomy group compared to late amniotomy group [27.3% versus 14.5% with a relative risk value of 1.88]. An increase in rate of cesarean section was primarily due to dystocia [52.4% versus 16.4% and a relative risk of 1.44] however, no significant difference was found in rate of cesarean section due to others indications. Also, the difference between Apgar score at 5 minutes among two groups was shown to be insignificant, statistically [P=0.15]. In women undergoing cervical ripening using a foley catheter, the augmentation of labor by oxytocin followed by amniotomy during active phase of labor results in shortening of duration of labor and also lower rate of cesarean section for dystocia

Efficacy of different methods of induction of labour

To determine the efficacy of different methods of induction of labour in term pregnancies, their impact on induction-delivery interval, mode of delivery and safety to mother and fetus. Prospective comparative study with quantitative design. Department of Obstetrics and Gynaecology Unit 1 Holy Family Hospital Rawalpindi from 1[st] January 2002 to 31[st] December 2002. Women between 37-42 weeks of gestation, with singleton pregnancy, cephalic presentation, having Bishop score between of 4 to 6 were included. Convenience sampling was done. Subjects for planned induction were allocated into three groups. Group I had labor induction with single PGE2 [Prostaglandin E2] 3mg vaginal pessary. Group II had amniotomy with simultaneous oxytocin infusion and Group III had extra amniotic Foleys Catheter [EAFC] insertion. Main outcome measures were increase in bishop score 6 hours post induction, induction to labor onset interval, induction to delivery interval, mode of delivery, any complication arising during induction process or afterwards and neonatal outcome. The number of cases included were 214, comprising of 78, 72 and 64 women in group I, II, and III respectively. The rise in bishop score was significantly higher in multipara in all the three groups. Induction to delivery interval was shortest in group II [7.6 hours +/- 4.2SD in primigravida and 6.9 hours +/- 2.9 SD in multigravida] as compared to the other two groups. The Caesarean section rate was 11.5%, 16% and 9.3% in the three groups respectively. Rate of failed induction was higher in EAFC group [4.6%] All the three modes of induction were equally safe and effective in terms of delivery and APGAR score. However each method of induction has its own merits and demerits. PGE2 was found to be least invasive and safe, while oxytocin infusion group required continuous monitoring for uterine contractions and titration on infusion while EAFC group showed a slightly higher incidence of neonatal sepsis

Amnion graft in vaginoplasty: an Experience at 3 teaching hospitals of Lahore

This study was carried out to determine the outcome of vaginoplasty using amnion graft. It was conducted in 3 different hospitals of Lahore including Lady Willingdon hospital. Sir Ganga Ram hospital, and General hospital from March 2001 to March 2005. Ten patients with Mayer-Rokitansky -Kauster-Hauser syndrome [MRKH] included in the study, underwent vaginoplasty using amnion graft. All patients were followed upto 6 months and beyond to determine the outcome of vaginoplasty and coital function. The patients' age ranged between 18-30 years. Eight patients [80%] were married and two were unmarried. The procedure was uncomplicated in nine while one had rectal injury, which was repaired successfully before application of graft. Follow up ranged upto 6months and beyond. Eight patients had excellent vaginal depth upto 8cm after 6months. One patient had cicatrisation. One patient lost follow-up. Five had satisfactory coital function. Ammon graft vaginoplasty is an ideal, simpler method and provides good results n ot only in terms of improvement in vaginal length but also couple's satisfaction at coitus

A comparative study of membrane stripping and nonstripping for induction of labor in uncomplicated term pregnancy.

A prospective, randomized controlled trial was undertaken at the Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn Hospital to determine whether stripping of the fetal membranes is a safe and effective method for induction of labor in uncomplicated term pregnancy. Ninety-six women were included in this study; 16 were excluded; 41 were randomized to a study group and 39 to a control group. Both groups had pelvic examination performed under sterile technique and a Bishop score was assessed. In the study group, membrane stripping was performed. Gentle pelvic examination for Bishop scoring was continued weekly in both groups. Thirty five of 41 women (85.4%) in the study group delivered within 7 days as compared to 22 of 39 women (56.4%) in the control group, a statistically significant difference (P = 0.004). A statistically significant difference was also observed with respect to the mean number of days to delivery (5.3 +/- 4.9 versus 9.5 +/- 5.9 days, respectively; P = 0.002). No statistically significant differences were observed in both maternal and fetal complications. In conclusion, membrane stripping is a safe and effective method for induction of labor in uncomplicated term pregnancy.

Obstetric performance, perinatal outcome and risk of infection to the newborn in spontaneous and artificial rupture of membranes during labour.

OBJECTIVE: To compare the obstetric performance, perinatal outcome and risk of neonatal infection in labour following spontaneous (SROM) and artificial (AROM) rupture of membranes. DESIGN: Prospective, non-randomised, comparative study during a one-month period in 1995. The study was approved by the ethics committee of the Faculty of Medicine, University of Colombo. SETTING: University Obstetrics Unit at De Soysa Hospital for Women, Colombo. PATIENTS: 324 women who were in early established labour after 37 weeks of gestation. 151 of these had SROM and 173 AROM. The AROM and SROM groups among primigravidae and multigravidae were considered separately. RESULTS: Oxytocin use in multigravidae was significantly higher in the AROM group than in the SROM group (p < 0.001). The emergency caesarean section (LSCS) rate in primigravidae was significantly higher in the AROM group than the SROM group (p < 0.001). A significantly larger number of primigravid AROM women had abnormal fetal heart rate changes on auscultation (p < 0.05) and cardiotopographic (CTG) patterns (p < 0.001) when compared with primigravid SROM women. Choreoamnionitis and funisitis were commoner in the AROM group although the difference was not statistically significant. CONCLUSIONS: AROM appears to be associated with a higher chance of fetal distress particularly in primigravidae. Both AROM and SROM are associated with a potential risk of infection at intrauterine sites.

Common bile duct reconstruction using vascularized support of a free amnion graft

Benign bile duct stricture is common in surgical practice. The complications of late stricture formation and biliary sepsis still occur in bile duct reconstruction. Many biologic and artificial materials have been used to replace the damaged bile duct to avoid bilio-enteric anastomosis, which bypasses the biliary sphincter mechanism. Non satisfactory biliary replacement material has yet been found, until the use of human amnion as a free graft or supported by vascularized flap. Non circumferential bile duct loss appeared to be satisfactorly repaired using amnion. However, circumferential duct loss was not adequately repaired with amnion graft only, so we used in our work the vascularized peritoneomuscular flap depending on one of the phrenic vessels to support the amnion graft, this improved much the results