Laparoscopic Uterine Artery Occlusion Combined with Uterine-sparing Pelvic Plexus Block and Partial Adenomyomectomy for Adenomyosis: A Video Case Report.

OBJECTIVE: Adenomyosis usually causes dysmenorrhea and anemia. Clinically, it is difficult to be treated with medicine or by traditional surgery, however, hysterectomy is always performed for radical treatment. In this article, we introduce a new method that could control the dysmenorrhea and the anemia through laparoscopic uterine artery occlusion (LUAO) combined with uterine-sparing pelvic plexus block and partial adenomyomectomy for uterus preservation. DESIGN: Surgical video article. Local institutional review board approval for the video reproduction was obtained. SETTING: A 42-year-old patient, who had a history of a previous cesarean delivery, was admitted to our department with complaints of progressive dysmenorrhea for more than 5 years and aggravated with anemia for 1 year. The patient had failed treatment with traditional Chinese medicine and gonadotropin-releasing hormone and had to take painkillers for nearly half a year. The patient had no desire for another pregnancy. After careful consideration, the patient strongly rejected hysterectomy and demanded the preservation of the uterus, insisting on the integrity of the organs. A gynecologic examination showed that the uterus was hard and enlarged similar to one that is more than 8 gestational weeks, without tender nodules in the rectouterine pouch. The visual analog scale pain score was 7, and her hemoglobin was 93 g/L (after correction). The preoperative magnetic resonance imaging implied that there was 1 lesion in the posterior wall and the maximum diameter of the lesion was 7.8 cm. INTERVENTIONS: We performed laparoscopic partial adenomyomectomy combined with occlusion of uterine artery to limit the amount of intraoperative bleeding, dissected the uterine branch of pelvic plexus nerve, and performed electrocoagulation blocking to relieve the dysmenorrhea. The specific operation procedures are as follows (Video): Firstly, we opened the peritoneum through Cheng's triangle, which contained the external iliac blood vessels, the round ligament, and the infundibulopelvic ligament (Fig. 1). Secondly, we separated the lateral rectal space and exposed the ureter, the internal iliac artery, the uterine artery, and the deep uterine vein. Thirdly, we found that the pelvic plexus was located on the outside of the sacral ligament and was approximately 2 to 3 cm below the ureter, going against the sacral ligament and passing through below the deep uterine vein (Supplemental Video 1). Fourthly, we separated the 4 layers of the paracervix [1]. The first layer included the internal iliac artery and the uterine artery. The second layer was the ureter. The third layer was the deep uterine vein. The last layer was the pelvic plexus, which involved the forward-going bladder branch, the inward-going uterine branch, and the downward-going rectal branch (Supplemental Video 2). These anatomic structures are similar to the complex architecture of an overpass called the Cheng's Cross [2] (Fig. 2). In this operation, only the uterine artery and the uterine branch would be blocked. Finally, we performed the partial adenomyomectomy. The endometrium, the myometrial tissues, and the serosa were repaired in some layers with continuous suture, depending on the depth of incision. The operation time was 92 minutes, and the intraoperative hemorrhage was approximately 50 mL. The patient was able to get out of bed on the first day after the operation and urinate after removing the catheter. On the second day after the surgery, the patient had exhaustion and defecation. From the third day after the surgery, gonadotropin-releasing hormone (Goserelin Acetate Sustained-Release Depot,3.6mg each, subcutaneous injection, name of the enterprise: AstraZeneca UK Limited) was used every 4 weeks, with a total of 3 times. Menstruation began on the 67th day after withdrawal of the drug. The results of postoperative condition of the patient followed up at 6 months after surgery were collected as follows: dysmenorrhea was significantly relieved (visual analog scale score was 2), hemoglobin was 123 g/L, and uterine volume was reduced to 43% of preoperative volume. The comparison of the patient's preoperative and postoperative magnetic resonance imaging showed that the uterus was approximately the same size as that of a woman of the same age, and the incision healed well (Fig. 3). CONCLUSION: Adenomyosis is a common gynecologic disease, mainly occurring in women of childbearing age. Adenomyosis is defined as endometrial glands and stroma that invade the myometrium and is surrounded by chronical inflammation in the endometrium [3]. Secondary dysmenorrhea and menorrhagia are the most common chief complaints in patients with adenomyosis, among which dysmenorrhea is the most unbearable symptom [2]. In the past, we had always treated adenomyosis by hysterectomy [4]. With the continuous pursuit of quality of life, it is difficult to meet clinical needs through drugs and traditional surgical methods. Uterine sparing surgery is a current trend in the treatment of adenomyosis, which enables women to maintain fertility and avoid the effects of hysterectomy on sexual function and mental discomfort. Dysmenorrhea can be divided into peripheral dysmenorrhea and central dysmenorrhea. According to our previous studies on dysmenorrhea, the uterine branch nerve has a controlling effect on dysmenorrhea [2]. The purpose of pelvic plexus uterine branch ablation is to further relieve dysmenorrhea by blocking nerve conduction pathways. Therefore, we selectively blocked the uterine branch nerve to alleviate the dysmenorrhea of adenomyosis. The uterine artery controls 90% of uterine blood flow. According to our team research, LUAO is an effective method to treat symptomatic uterine myomas and adenomyosis. We investigated the morphologic change and apoptosis occurring in myomal and adjacent myometrial tissues after LUAO. We concluded that apoptosis through mitochondrial pathways may lead to reduction of the volume of myoma and myometrium and eventually relief of symptoms [5,6]. We speculated "single organ shock uterine" to explain uterine artery occlusion (UAO) mechanism, which was different from uterine artery embolization. The single organ shock theory of UAO can still inhibit the growth of myomas effectively. It is difficult to completely remove adenomyosis lesions during surgery, especially for diffuse adenomyosis. Therefore, in our team, we performed UAO combined with resection of focal lesions in key areas for patients with diffuse adenomyosis, instead of pursuing radical resection [7,8]. The purpose of UAO is to reduce the amount of bleeding during surgery and further atrophy of residual and scattered adenomyosis lesions in utero [5,6]. The intraoperative blocking of the uterine artery can reduce intraoperative bleeding and operation time, improve operation quality, and decrease recurrence rate. In our team, this technique has been used in clinic for more than 10 years. Our previous studies have shown that LUAO combined with pelvic plexus uterine branch nerve block and resection of most of the adenomyosis has achieved satisfactory clinical efficacy as a treatment for adenomyosis [2,3]. With this procedure, we can help patients with adenomyosis retain their uterus and relieve the anxiety caused by hysterectomy. In conclusion, UAO and uterine branch ablation in uterine sparing laparoscopic treatment is a safe and effective method, which may be considered as a good choice for symptomatic adenomyosis.

Magnetic bio-activated carbons production using different process parameters for phosphorus removal from artificially prepared phosphorus-rich and domestic wastewater.

A series of magnetic bio-activated carbon (MBAC) has been produced from lignin and ferrous salts following to the process including impregnation, carbonization, and steam activation. The influence of the impregnation methods and the steam flow rate on the quality and the maximum phosphorus adsorption capacity of the produced MBACs has been investigated. The phosphorus adsorption performance in real domestic wastewater of the MBAC with the highest maximum phosphorus adsorption capacity has been investigated. The results show that all of the produced MBACs have a relatively rich porous structure, and all surface iron species exist as magnetite (Fe3O4). Compared with the MBACs that are produced via the dry impregnation method using a lower steam flow rate, the MBACs that are produced via the wet impregnation method using a higher steam flow rate are believed to have a higher iron content and better iron species dispersion. The highest maximum phosphorus adsorption capacity of all the produced MBACs is estimated to be as high as 69.80 mg-P/g according to the best-fitting Langmuir model. The MBAC that shows the highest maximum phosphorus adsorption capacity could also remove 84.65% and 96.97% of the total phosphorus from the filtered raw domestic wastewater (FRDW) and treated domestic wastewater (TDW), respectively, which indicates a good potential for using MBACs for domestic wastewater treatment.

Traditional Chinese Medicine symptom patterns in patients with colorectal carcinoma.

OBJECTIVE: To observe the symptom patterns (or syndromes) according to Traditional Chinese Medicine (TCM) theory in patients with various stages of colorectal cancer, and to observe the dynamic evolution process of these TCM patterns. METHODS: A prospective and cross-sectional questionnaire-based investigation was performed. Clinical data on TCM symptom patterns in patients with colorectal cancer in the perioperative period (210 cases) and adjuvant treatment period (160 cases) were collected. EPIData 3.1 together with frequency statistics and cluster analyses were performed to identify the TCM patterns based on symptom characteristics in patients with colorectal cancer, and to assess the dynamic changes in these patterns. RESULTS: In the perioperative period, from the first day of perioperative care to postoperative days 3, 7, and 10, the TCM pattern showed a process of dynamic change from blood deficiency to deficiency of both Qi and Yin and the pattern of dampness and hot accumulative knotting. In the adjuvant treatment period, the TCM pattern changed from Qi deficiency and Yin deficiency inner-heat with dampness to a deficiency pattern, primarily including Yin deficiency of the liver and kidney, deficiency of Qi and blood, and spleen deficiency. CONCLUSION: Our study confirmed that variations in the dynamic evolution of TCM symptom patterns exist in patients with colorectal cancer during different treatment periods. This information is of great value in the individualized management of colorectal cancer.

Study on Chinese medicine syndrome of colorectal carcinoma in perioperative period.

OBJECTIVE: To explore the distribution characteristics of Chinese medicine (CM) syndromes and the rule of dynamic evolvement in patients with colorectal cancer at the perioperative period by applying a mathematical statistics methodology. METHODS: By using the overall sample date, and cross-sectional descriptive and prospective researching methods, the clinical data of CM symptoms of patients with colorectal cancer from the first day of preoperative care to the third, seventh, and tenth days after the operation were collected. The distribution characteristics of CM syndromes and dynamic evolution were concluded upon by experts, and then by building up a database through the use of EpiData3.1 the frequency statistics and cluster analyses were applied utilizing SAS9.2 software. RESULTS: Among 210 cases of patient, on the day before the operation, the main route of syndrome was blood deficiency (33.33%), followed by the syndrome of deficiency of both qi and yin (28.57%). On the third day after surgery, the main syndrome was qi deficiency (47.62%), followed by yin deficiency inner-heat. On the seventh day after surgery, the main syndrome was both yin deficiency inner-heat (33.33%) and phlegm-dampness (33.33%). On the tenth day after surgery, the main syndrome was a deficiency of both qi and yin (38.09%), followed by dampness and hot accumulative knotting (33.33%). CONCLUSION: Research in the field of the distribution characteristics of CM syndromes and dynamic evolution will provide an objective basis for syndrome differentiation for patients in the perioperative period, further advancing the study of preventing and decreasing relapse and metastasis in CM therapy.

[Observation on therapeutic effect of comprehensive therapy on optic atrophy complicated by cerebral palsy].

OBJECTIVE: To assess therapeutic effect of combined treatment of Chinese medicine and western medicine on optic atrophy complicated by cerebral palsy. METHODS: One hundred and seventeen cases were divided into an observation group (n = 79) and a control group (n = 38). The control group were treated with routine western medicine treatment including neurotrophic drugs and high pressure oxygen, etc. and the observation group with acupuncture at Ganshu (BL 18), Pishu (BL 20), Chengqi (ST 1), etc. and injection of 0.2-0.3 mL Compound Danshen Injectio into Qiuhou (EX-HN 7), on the basis of the same treatment of western medicine as that in the control group. Fundus examination and the tracing body angle detection were conducted before and after treatment and the therapeutic effects were assessed in the two groups. RESULTS: The total effective rate was 91.1% in the observation group and 60.5% in the control group with a significant difference between the two groups (P < 0.001); after treatment the angle of tracing body significantly increased in the two groups (P < 0.01) with the observation group better than the control group (P < 0.01). CONCLUSION: The combined treatment of Chinese medicine and western medicine is an effective therapy for optic atrophy complicated by cerebral palsy.

Preventive effects of nitroglycerine on glucocorticoid-induced osteoporosis in growing rats.

The preventive effects of nitroglycerine (NG) on glucocorticoid-induced osteoporosis in growing rats were studied. Three-month-old female Wistar rats were randomly divided into control group (CON), dexamethasone group (DXM), DXM plus a low dose NG group (NG-L), DXM plus a middle dose NG group (NG-M) and DXM plus a high dose NG group (NG-H), 8 rats in each group. The rat model of osteoporosis was developed by intramuscular injection of dexamethasone twice a week. NG 0.2, 0.4 and 1.0 mg/kg was administered by oral gavages to the treatment groups every day for 12 weeks. Rats in CON group and DXM group were treated with normal saline of the same amount. After the treatment, the bone mineral density (BMD) and bone metabolism-associated biochemical markers were determined. Compared with CON group, BMD of lumbar spine and femur in DXM group was decreased significantly (P<0.05 and P<0.01 respectively), blood BGP levels and NO levels reduced (both P<0.01), and TRAP level increased (P<0.05). As compared with DXM group, BMD, serum BGP and NO were increased, and TRAP decreased in NG-L group and NG-M group, but had no significant difference in comparison to CON group. All the markers other than serum NO and TRAP levels had no significant difference between NG-H group and DXM group. It was concluded that low or middle doses of NG could prevent glucocorticoid-induced bone loss in growing rats, but high dose of NG could not. Supplement with NO donor could be considered as a preventive treatment for glucocorticoid-induced osteoporosis in a developing skeleton.