Barbed vs conventional sutures for cesarean uterine scar defects: a randomized clinical trial.

BACKGROUND: The role of barbed sutures in preventing myometrial defects and enhancing postpartum outcomes after cesarean section (C-section) is uncertain. OBJECTIVE: This study compared clinical and ultrasonographic outcomes of uterine scar defects after C-section with barbed and conventional smooth thread sutures. STUDY DESIGN: This was a multicenter, parallel-group, randomized, controlled clinical trial. Four obstetrics and gynecology departments across three Japanese healthcare regions were included. The participants were women requiring their first cesarean delivery between May 2020 and March 2023. Of the 1211 participants enrolled, 298 underwent C-section and 253 were followed up until July 2023. Participants with singleton pregnancies were randomly assigned (1:1 ratio) to receive either conventional or spiral thread sutures with a double-layer continuous suture. The study period comprised the time of consent to the 6- to 7-month examination. The primary endpoint was the rate of scar niches >2 mm evaluated using transvaginal ultrasonography at 6 to 7 months after surgery. Additional metrics included the total operative time, suture application time, operative blood loss, number of additional sutures required for hemostasis, maternal surgical complications, postoperative infections, surgeon's years of experience, and individual subscale scores. RESULTS: All data of the 220 participants (barbed suture group: 110; conventional suture group: 110) were available, thus enabling a full analysis set. A comparison of the barbed and conventional suture groups, respectively, revealed the following: niche length, 2.45±1.65 mm (range: 1.0-6.7) vs 3.79±1.84 mm (range: 1.0-11.0) (P<.001); niche depth, 1.78±1.07 mm (range: 1.0-5.7) vs 2.70±1.34 mm (range: 1.0-7.3) (P<.001); residual myometrial thickness (RMT), 8.46±1.74 mm (range: 4.8-13.0) vs 7.07±2.186 mm (range: 2.2-16.2) (P<.001); and niche width, 1.58±2.73 mm (range: 0.0-14.0) vs 2.88±2.36 mm (range: 0.0-11.0) (P<.001), respectively. The barbed suture group exhibited no defects and an RMT <3 mm. Furthermore, the barbed suture group had a lower rate of uterine niches (29.1%; n=32/110) than the conventional suture group (68.2%; n=75/110). Secondary outcomes showed no significant differences in operative times, maternal surgical complications, or postoperative complications. CONCLUSION: Double-layer barbed sutures during cesarean delivery may prevent C-section scar defects and postoperative complications.

Frequency and clinical features of deficient mismatch repair in ovarian clear cell and endometrioid carcinoma.

OBJECTIVE: To clarify the frequency of deficient mismatch repair (dMMR) in Japanese ovarian cancer patients, we examined microsatellite instability (MSI) status and immunohistochemistry (IHC) subtypes, including endometrioid carcinoma (EMC), clear cell carcinoma (CCC), or a mixture of both (Mix). METHODS: We registered 390 patients who were diagnosed with EMC/CCC/Mix between 2006 and 2015 and treated at seven participating facilities. For 339 patients confirmed eligible by the Central Pathological Review Board, MSI, IHC, and MutL homolog 1 methylation analyses were conducted. The tissues of patients with Lynch syndrome (LS)-related cancer histories, such as colorectal and endometrial cancer, were also investigated. RESULTS: MSI-high (MSI-H) status was observed in 2/217 CCC (0.9%), 10/115 EMC (8.7%), and 1/4 Mix (25%). Additionally, loss of MMR protein expression (LoE-MMR) was observed in 5/219 (2.3%), 16/115 (14.0%), and 1/4 (25%) patients with CCC, EMC, and Mix, respectively. Both MSI-H and LoE-MMR were found significantly more often in EMC (p<0.001). The median (range) ages of patients with MMR expression and LoE-MMR were 54 (30-90) and 46 (22-76) (p=0.002), respectively. In the multivariate analysis, advanced stage and histological type were identified as prognostic factors. CONCLUSION: The dMMR rate for EMC/CCC was similar to that reported in Western countries. In Japan, it is assumed that the dMMR frequency is higher because of the increased proportion of CCC.

The Spiral Trial: A multicenter, randomized, controlled trial of Spiral thread sutures versus conventional thread sutures to prevent thinning of uterine scars following elective cesarean section.

BACKGROUND: The aim of this randomized controlled trial (RCT) is to investigate whether Spiral-thread sutures are superior to conventional sutures (0-Vicryl) for preventing uterine scar thinning following elective cesarean section. METHODS: This multicenter, parallel-group RCT will be conducted in four hospitals across three medical regions in Japan to assess 200 women (≥20 years old) with singleton pregnancies who are scheduled to undergo cesarean sections. Eligible women will be randomly assigned (1:1 ratio) to receive either the conventional uterine suture continuous absorption thread, which is most commonly used in Japan, or the Spiral thread. The primary endpoint is the degree of scar thinning, measured by transvaginal ultrasonography 6-7 months postoperatively, to evaluate the position of the uterus (anterior or posterior tilt) and myometrial wound thickness. The degree of thinning will be compared between the groups, and four measurements (mm) of the thinning area, including caudal distance, depth of the depression, remaining thickness of the myometrium on the serous side of the most depressed area, and width of the depression, will be recorded in the sagittal view on transvaginal ultrasound. Secondary endpoints will include total operative time, suture application time (from birth to the end of uterine suturing), operative blood loss, number of additional Z-sutures or continuous sutures required to stop bleeding, maternal abnormality frequency (surgical complications and postoperative infections), surgeon's years of experience, and clinical interpretation of individual subscale scores. DISCUSSION: This study shall provide important evidence on the optimal suture for preventing hysterotomy wound thinning after the first cesarean section. TRIAL REGISTRATION: National Institute of Public Health, Japan: jRCT1062200001 (May 7, 2020; https://rctportal.niph.go.jp/en/detail?trial_id=jRCT1062200001) and Okayama University Certified Review Board: CRB6180001 (April 9, 2020, version 3.0).

Prenatally diagnosed congenital pyloric atresia in consecutive three siblings: a case report.

BACKGROUND: Congenital pyloric atresia (CPA) is a rare gastrointestinal anomaly frequently associated with epidermolysis bullosa (EB). Although the complications of familial isolated CPA are minor, delays in diagnosis can increase the chances of morbidity. CASE PRESENTATION: Three female infants born to a Japanese mother presented with CPA at birth. There was no consanguinity between the parents, and the spacing between pregnancies was 2 years in each case. All 3 siblings had a prenatal diagnosis of CPA owing to polyhydramnios and a dilated stomach, without dilatation of the rest of the gastrointestinal tract. All patients underwent reconstructive surgeries for establishing bowel continuity (Case 1, pyloromyotomy; Case 2, gastroduodenostomy in a diamond fashion; and Case 3, gastroduodenostomy in a side-to-side fashion) soon after birth. Their postoperative courses were uneventful, and they grew up healthily, without any complications. CONCLUSION: Fetal ultrasonography is useful for diagnosing CPA prenatally. Successful prenatal diagnosis can lead to timely intervention after birth.

Splenic metastasis of squamous cell carcinoma of the uterine cervix: a case report and review of the literature.

Metastasis from various neoplasms to the spleen is very rare and most of the cases are found at autopsy. We report a patient presenting with uterine cervical cancer with splenic metastases. A 49-year-old woman presenting with genital bleeding was referred to our hospital and diagnosed with stage IIB cervical cancer. She underwent concomitant chemoradiotherapy (CCRT) consisting of 50 Gy whole pelvis irradiation, high-dose-rate intracavitary brachytherapy 24 Gy/4 fractions and six weeks of paclitaxel and carboplatin administration. Ten months after the initial therapy, CT revealed recurrence at spleen. Although she received 5 courses of nedaplatin, enlargement of the tumor was noticed. She underwent a splenectomy and the result of histology was compatible with metastasis of cervical cancer.

A case of adenosarcoma of the uterus.

Adenosarcoma is a rare tumor which consists of benign glandular epithelium and malignant mesenchymal component. Here we report a case of adenosarcoma of the uterine corpus. Case Presentation. A 59-year-old woman presented with vaginal bleeding and visited a local clinic. She had a uterine tumor pointed out and was referred to our hospital. Ultrasound scans revealed a large heterogeneous mass occupying the whole uterine cavity. Cytological test of endometrium was performed but the result was negative. A fractional endometrial curettage revealed no malignancy. Magnetic resonance imaging (MRI) revealed a heterogeneous solid tumor of 77 × 76 mm. Total abdominal hysterectomy with bilateral salpingo-oophorectomy and pelvic lymphadenectomy was performed. On gross examination, the tumor was arising from the uterine body and occupied the whole uterine cavity. Histopathological examination revealed phyllodes-like architecture on low magnificationandperiglandular cuffing of tumor cells. The lesion was confined to the uterus. Histopathological final diagnosis was adenosarcoma. Her postoperative course was uneventful and she was discharged without postoperative treatment and remains alive without disease 6 months after the surgery.

A case of endometrioid adenocarcinoma arising from adenomyosis.

Malignant changes in endometriosis are often reported, but those in adenomyosis are rare. We report a case of endometrioid adenocarcinoma arising from adenomyosis. Case Presentation. A 57-year-old woman presenting with vaginal bleeding was referred to our hospital. Cytological tests of endometrium revealed atypical glandular cells. Fractional endometrial curettage revealed normal endometrium without atypia. Magnetic resonance imaging (MRI) revealed multiple myomas. The endometrium was slightly enhanced on T1-weighted imaging and endometrial cancer was suspected. Myometrial invasion was not evident. The patient was admitted and semiradical hysterectomy with bilateral salpingo-oophorectomy and pelvic lymphadenectomy was performed. Histopathological study revealed grade 1 endometrioid adenocarcinoma. Although the lesion was located in the muscle layer of the corpus and invaded more than half of it, the endometrium was intact. Pelvic lymph node metastasis was noticed. No cervical invasion or metastasis to the adnexa was seen. We diagnosed the case with a stage 1B endometrioid adenocarcinoma originating from adenomyosis. Adjuvant chemotherapy was then performed in the form of 5 cycles of paclitaxel (180 mg/m(2)) and carboplatin (AUC = 5). Five years later, right lung metastasis and right para-aortic and pelvic lymph nodes metastasis were noticed. Paclitaxel and carboplatin are now being administered.

A case of placental mesenchymal dysplasia.

Placental mesenchymal dysplasia (PMD) rarely complicates with pregnancy. A 30-year-old woman, gravida 3, para 3, presenting with placentomegaly, was referred to our department at 18 weeks of gestation. An ultrasonography revealed a normal fetus with a large multicystic placenta, measuring 125 × 42 × 80 mm. The border between the lesion and normal region was not clear. Color doppler revealed little blood flow in the lesion. Magnetic resonance imaging revealed normal fetus and a large multicystic placenta. Serum human chorionic gonadotropin level was 20124.97 U/L, which was normal at 20 weeks of gestation. Thus, placental mesenchymal dysplasia rather than hydatidiform mole with coexistent fetus was suspected. Then, routine checkup was continued. Because she had the history of Cesarean section, an elective Cesarean section was performed at 37 weeks of gestation, and 2520 g female infant with apgar score 8/9 was delivered. The baby was normal with no evidence of Beckwith-Wiedemann syndrome. Placenta of 20 × 16 × 2 cm, weighing 720 g, was bulky with grape like vesicles involving whole placenta. Microscopic examination revealed dilated villi and vessels with thick wall which was lacking trophoblast proliferation. Large hydropic stem villi with myxomatous struma and cistern formation were seen. PMD was histopathologically confirmed.