Adhesions and endometriosis: challenges in subfertility management : (An expert opinion of the ANGEL-The ANti-Adhesions in Gynaecology Expert PaneL-group).

There is molecular evidence that endometriosis has a negative impact on the ovaries, although the exact pathophysiology concerning endometriosis-associated subfertility is not known. The negative impact on the tubo-ovarian unit can be directly by distorting the anatomy, indirectly by invoking inflammation or by oxidative damage with poorer-quality oocytes. Endometriosis even seems to have a negative effect on pregnancy outcome after in vitro fertilization.

Improved survival of patients with ovarian cancer in Northern Denmark, 1985-2004.

OBJECTIVE: Ovarian cancer is a serious disease with a high mortality. Our aim was to examine changes in the survival of patients with ovarian cancer in Northern Denmark. STUDY DESIGN AND SETTING: Patients (no. = 3,719) with an incident discharge diagnosis of ovarian cancer (1985-2004) from any hospital in four Danish counties (population, 1.6 million) were included and tracked for mortality through the Danish Civil Registration System. We determined survival and mortality rates stratified by age, and used Cox proportional hazard regression analyses to assess changes over time. RESULTS: Overall survival rate improved between 1985 and 2004. One-year survival increased from 61% to 73%, and five-year survival from 30% to 38%. Compared with the period 1985-1989 the age-adjusted one-year mortality rate ratio (MRR) was 0.65 (2000-2004) and the age-adjusted five-year MRR was 0.80 (1995-1999). The improvement was most pronounced in patients older than 40 years. CONCLUSION: The survival of ovarian cancer patients has improved in Denmark in recent decades. This change may be the result of improved treatment.

Laparoscopy for abdominal emergencies: evidence-based guidelines of the European Association for Endoscopic Surgery.

BACKGROUND: Emergency laparoscopic exploration can be used to identify the causative pathology of acute abdominal pain. Laparoscopic surgery also allows treatment of many intraabdominal disorders. This report was prepared to describe the effectiveness of laparoscopic surgery compared to laparotomy or nonoperative treatment. METHODS: A panel of European experts in abdominal and gynecological surgery was assembled and participated in a consensus conference using Delphi methods. The aim was to develop evidence-based recommendations for the most common diseases that may cause acute abdominal pain. RECOMMENDATIONS: Laparoscopic surgery was found to be clearly superior for patients with a presumable diagnosis of perforated peptic ulcer, acute cholecystitis, appendicitis, or pelvic inflammatory disease. In the emergency setting, laparoscopy is of unclear or limited value if adhesive bowel obstruction, acute diverticulitis, nonbiliary pancreatitis, hernia incarceration, or mesenteric ischemia are suspected. In stable patients with acute abdominal pain, noninvasive diagnostics should be fully exhausted before considering explorative surgery. However, diagnostic laparoscopy may be useful if no diagnosis can be found by conventional diagnostics. More clinical data are needed on the use of laparoscopy after blunt or penetrating trauma of the abdomen. CONCLUSIONS: Due to diagnostic and therapeutic advantages, laparoscopic surgery is useful for the majority of conditions underlying acute abdominal pain, but noninvasive diagnostic aids should be exhausted first. Depending on symptom severity, laparoscopy should be advocated if routine diagnostic procedures have failed to yield results.

Clinical evaluation of a viscoelastic gel for reduction of adhesions following gynaecological surgery by laparoscopy in Europe.

BACKGROUND: Commonly used adhesion prevention devices either cannot be applied or are difficult to use via laparoscopy. A viscoelastic gel was developed specifically for adhesion prophylaxis during minimally invasive surgery. METHODS: Randomized, third party-blinded, parallel-group design conducted at four centres. Patients (18-46 years old) underwent laparoscopic surgery with second look 6-10 weeks later. Viscoelastic gel coated adnexa and adjacent tissues. Blinded reviews of videotapes were quantified by American Fertility Society (AFS) adhesion scores. RESULTS: In 25 treatment patients, surgery was performed on 45 adnexa. Coverage of surgical sites at risk for adhesions was typically accomplished with approximately 15 ml of viscoelastic gel which was delivered in approximately 90 s. In 24 control patients, surgery alone was performed on 41 adnexa. Treated adnexa showed a decrease in AFS score (11.9-9.1). In contrast, control adnexa showed an increase in AFS score (8.8-15.8). This difference in second-look AFS scores (42% reduction) is significant (P<0.01). Ninety-three per cent of treated adnexa did not have a worse adhesion score in contrast to 56% of control adnexa. Combining scores into prognostic categories also show significant treatment effect of the viscoelastic gel (P<0.01). CONCLUSION: Viscoelastic gel was easy to use via laparoscopy and produced significant reduction in adnexal adhesions. It provides benefits to patients undergoing gynaecological surgery.

Reduction of post-surgical adhesions with ferric hyaluronate gel: a European study.

BACKGROUND: The objective of this study was to assess the safety and efficacy of a 0.5% ferric hyaluronate gel, in reducing adhesions in patients undergoing peritoneal cavity surgery by laparotomy, with a planned 'second-look' laparoscopy. METHODS: The study was a randomized (by computer-generated schedule), third party blinded, placebo-controlled, parallel-group design conducted at five centres in Europe. Females aged 18-46 years received 300 ml ferric hyaluronate (n = 38) or lactated Ringer's (n = 39) as an intraperitoneal instillate at the completion of surgery. At second-look 6-12 weeks later, the presence of adhesions was evaluated at 24 abdominal sites. RESULTS: Patients treated with ferric hyaluronate had significantly fewer adhesions compared with controls. When adhesions formed, they were significantly less extensive and less severe in the treated group. The American Fertility Society score for adnexal adhesions was reduced by 69% in the treatment group compared with controls. The safety profile of ferric hyaluronate-treated patients was comparable with those treated with lactated Ringer's solution. CONCLUSIONS: In conclusion, ferric hyaluronate was safe and highly efficacious in reducing the number, severity and extent of adhesions throughout the abdomen following peritoneal cavity surgery.

Laparoscopic surgery in ectopic pregnancy.

BACKGROUND: A randomized, prospective clinical trial was conducted to compare the efficacy of laparoscopic treatment versus conventional conservative abdominal surgery for tubal pregnancy. METHODS: Patients were stratified for age and risk determinants for ectopic pregnancy (EP). Forty-eight patients were treated by laparoscopy and 57 by laparotomy. Entry criteria were: size of the ectopic gestation < 4 cm, hemodynamic stability, accessibility for laparoscopic treatment and a trained laparoscopist on duty. RESULTS: There was no difference between the groups regarding gestational duration, size and location of the ectopic gestation, and the mean preoperative hCG values. The groups did differ with respect to total operation time (73 min in the laparoscopy group vs. 88 min in the laparotomy group), hospital stay (2.2 days vs. 5.4 days) and convalescence period (11 days vs. 24 days). The rates of elimination of hCG were similar in the two groups, and there was no statistical difference in the rate of second intervention. CONCLUSIONS: Patients treated by laparoscopy had a shorter hospital stay and a shorter convalescence than patients from the laparotomy group.

A cost-effectiveness study of a randomised trial of laparoscopy versus laparotomy for ectopic pregnancy.

We compared the cost-effectiveness of therapeutic laparoscopy and open laparotomy for treatment of laparoscopically diagnosed ectopic pregnancy. Clinical outcomes of ectopic pregnancy treatment were based on results of a randomised trial done between 1987 and 1989 at Sahlgrenska University Hospital (Göteborg, Sweden). We estimated costs for inpatient and follow-up care of ectopic pregnancy by the two methods. Observed resource use (eg, procedure duration) was multiplied by 1992 estimates of resource unit cost (eg, cost per minute of laparoscopy time), based on detailed internal cost accounting data from Huddinge University Hospital. By specified criteria, the initial procedure eliminated trophoblastic activity without major complications in 81% (95% CI: 68-90) of 52 laparoscopy patients, versus 95% (85-99) of 57 laparotomy patients. Residual trophoblast or complications were successfully treated in all remaining patients. Mean simulated costs (standard error) for the overall laparoscopy strategy were 28,058 (1780) Swedish kronor versus 32,699 (1080) kronor for laparotomy (p = 0.03). In the baseline simulation and most sensitivity analyses, laparoscopy produced final outcomes equivalent to those of laparotomy at lower costs. As laparoscopic outcomes improve, this newer approach should become increasingly preferable.

Coecal volvulus following caesarean section.

A case of coecal volvulus following caesarean section is reported. The importance of knowing the possibility of intestinal obstruction during pregnancy and puerperium is underlined.

[Fertility after conservative surgical treatment of ectopic pregnancy, evaluated by a randomized trial]. / Fertilitet efter konservativ kirurgisk behandling af ekstrauterin graviditet, evalueret i et randomiseret studie.

In order to evaluate the fertility outcome after laparoscopic surgery for ectopic pregnancy, randomised trial of laparoscopy versus laparotomy was performed between May 1987 and June 1989. The study was conducted in a clinical university centre, Sahlgrens Hospital. A group a 105 patients with tubal pregnancy were stratified with regard to risk determinants and age randomized to laparoscopy or laparotomy. Eighty-seven patients who desired pregnancy were evaluated for subsequent fertility outcome. Linear salpingotomy was performed in both groups. The fertility outcome after laparoscopic salpingotomy was compared with that following laparotomy. There was no difference between the groups in the overall fertility outcome. A substantially higher proportion of patients in the laparotomy group were subjected to adhesiolysis performed at a second-look laparoscopic surgery. Adhesiolysis at a second-look laparoscopy, especially after laparotomy, might be beneficial in selected cases and may serve to improve subsequent fertility.

Fertility outcome after conservative surgical treatment of ectopic pregnancy evaluated in a randomized trial.

OBJECTIVE: To evaluate the fertility outcome after laparoscopic surgery for ectopic pregnancy. DESIGN: A randomized trial versus laparotomy was performed between May 1987 and June 1989. SETTING: The study was conducted in a clinical university center, the Sahlgrens Hospital. PATIENTS: A group of 105 patients with tubal pregnancy were stratified with regard to risk determinants and age and randomized to laparoscopy or laparotomy. Eighty-seven patients who desired pregnancy were evaluated for subsequent fertility outcome. INTERVENTIONS: Linear salpingotomy was performed in both surgical groups. MAIN OUTCOME MEASURE: We evaluated the fertility outcome after laparoscopic salpingotomy for comparison with the outcome after laparotomy. RESULTS: There was no difference between the groups in the overall fertility outcome. A substantially higher proportion of patients in the laparotomy group were subjected to adhesiolysis performed at a second-look laparoscopy. CONCLUSIONS: The fertility prospects are not impaired by laparoscopic surgery. Adhesiolysis at a second-look laparoscopy, especially after laparotomy, might be beneficial in selected cases and may serve to improve subsequent fertility.

Diagnosis and treatment of tubal pregnancy as related to risk determinants.

To evaluate whether identification of 'high risk' patients for ectopic pregnancy (EP) is beneficial for early recognition and treatment, 178 cases of tubal pregnancy were analysed. Patients with 'high risk' and 'low risk' for EP were compared for diagnostic procedures, clinical features and surgical management. The 'high risk' patients presented a shorter gestational length, lower blood loss volume, a smaller size of the tubal gestation, a lower rate of tubal rupture and underwent more conservative treatment. We conclude that identification of risk determinants may be of great importance for early recognition and hence, application of the new modalities for treatment of ectopic pregnancy.

Adhesion formation after laparoscopic surgery in tubal pregnancy: a randomized trial versus laparotomy.

OBJECTIVE: Women with ectopic pregnancy (EP) who have been operated on by laparoscopy are thought to have improved subsequent fertility, probably because of less adhesion formation. We aimed to evaluate the adhesion formation after laparoscopy as compared with laparotomy in a randomized trial. DESIGN: One hundred five patients with tubal pregnancy were stratified with regard to age and risk factors and randomized to surgery by laparoscopy or laparotomy. To evaluate adhesion formation and tubal status, 73 patients with strong desire of pregnancy underwent a second-look laparoscopy. The adhesion status at the ipsilateral and contralateral side at primary surgery was compared with the status at second-look laparoscopy. RESULTS: Patients operated on by laparotomy developed significantly more adhesions at the operated side than patients operated on by laparoscopy (P less than 0.001). Substantially more patients in the laparotomy group underwent adhesiolysis at second-look laparoscopy than did patients in the laparoscopy group. Tubal patency did not differ between the groups. CONCLUSIONS: Laparoscopic treatment of EP results in less impairment of the pelvic status compared with conventional conservative surgery.

Persistent trophoblast after conservative treatment of tubal pregnancy: prediction and detection.

The incidence of persistent trophoblast and risk of second surgical intervention after conservative treatment of tubal pregnancy are substantial. The preoperative and postoperative hCG patterns in patients with tubal pregnancy were studied to see whether this information could predict and detect persistent trophoblast at an early stage. Ninety-eight women with tubal pregnancy underwent conservative surgical treatment by laparoscopy or laparotomy. Eight developed postoperative complications necessitating a second operation, and seven of them had both biochemical and histologic evidence of persistent trophoblastic activity. In seven of 31 patients with preoperative hCG above 3000 IU/L, a second operation was necessary, whereas in 67 with preoperative hCG levels below 3000 IU/L, only one such intervention was necessary. Eight of the 22 patients with hCG above 1000 IU/L on the second day after surgery and seven of 11 patients with hCG above 1000 IU/L on the seventh day after surgery later needed a second surgical procedure. In contrast, 86 of 87 women with hCG below 1000 IU/L on the seventh day after surgery had an uneventful convalescence. We conclude that pre- and postoperative hCG measurements can identify patients at risk of developing persistent trophoblast. Further, in patients with preoperative hCG titers below 3000 IU/L, we recommend conservative surgery followed by measurement of hCG 1 week postoperatively.

Laparoscopic surgery in ectopic pregnancy. A randomized trial versus laparotomy.

A randomized, prospective clinical trial was conducted to compare the efficacy of laparoscopic treatment with conventional conservative abdominal surgery for tubal pregnancy. Entry criteria were: size of the ectopic gestation less than 4 cm, hemodynamic stability, accessibility for laparoscopic treatment and a trained laparoscopist on duty. There was no difference between the groups regarding gestational duration, size and location of the ectopic gestation, or the mean preoperative hCG values. The groups differed with respect to total operation time (73 min for the laparoscopy group vs. 88 min for the laparotomy group), hospital stay (2.2 vs. 5.4 days) and convalescence period (11 vs. 24 days). The rates of elimination of hCG was similar in the groups, and there were no statistical difference in the rate of second intervention.

Treatment of tubal pregnancy by laparoscope-guided injection of prostaglandin F2 alpha.

Twenty-six cases of unruptured tubal pregnancy were treated by laparoscope-guided injection of prostaglandin (PG) F2 alpha into the affected tube and the ovary containing the corpus luteum. Preoperative serum human chorionic gonadotropin (hCG) levels were 22 to 2,050 IU/L (mean 328 IU/L). The procedure was successful in 24 patients (92%), as indicated by reduction of hCG values to less than 20 IU/L. The remaining 2 cases showed an initial fall in hCG after injection and thereafter a plateau phase indicating the persistence of trophoblast. In both cases, a second surgical intervention was necessary. The total subsequent conception rate among 19 women desiring pregnancy was 90% (17/19). The intrauterine conception rate was 58% (11/19), and the repeat rate of ectopic pregnancy was 32% (6/19). Two-thirds (12/19) of the subsequent pregnancies occurred within 6 months "at risk" for conception. It is concluded that local injection of PGF2 alpha represents an attractive method for termination of selected cases of tubal pregnancy, preferentially in subjects with low trophoblastic activity.