The endogenous oxytocin after manipulative osteopathic treatment in full-term pregnant women.

OBJECTIVE: The aim of this study is to assess whether the touch of osteopathic manipulative treatment (OMT) can affect the endogenous production of oxytocin in full-term pregnant women and the assessment of well-being following the treatment. PATIENTS AND METHODS: In this study have been enrolled 57 pregnant women at full-term pregnancy (37th-41st week) for evaluation of the concentration of salivary oxytocin 2 minutes before and 2 minutes after a single session of OMT by an osteopath lasting for 30 minutes. Pre-OMT and post-OMT saliva samples were collected with the use of Salivette® salivary swabs. 7 salivary swabs were excluded from the analysis. 50 samples were analyzed with an appropriate ELISA kit. RESULTS: The mean OT salivary concentration pre-OMT was 89.98±16.39, and post-OMT was 100.60±19.13 tends to increase with p=0.0000051. In multivariate analysis, two subgroups show interesting data in the mean difference in OT salivary concentration post-OMT: women with painful contractions (p=0.06) and women under 35 years (p=0.09). CONCLUSIONS: The results of this study demonstrate that the effectiveness of OMT-increasing endogenous oxytocin is statistically significant in full-term pregnant women. The sensation of well-being found in most women indicates that there has been a predominantly central rather than peripheral oxytocin release after OMT.

The role of peritoneal lavage in benign gynecologic laparoscopic surgery.

OBJECTIVE: Laparoscopic surgery offers many advantages compared to invasive surgery but one of the main problems is postoperative pain, partially resulting from the peritoneal inflammatory process mediated by inflammatory cytokines. The rationale of this study is that intraperitoneal washing could remove inflammatory mediators that are the cause of postoperative pain and could help in the removal of CO2 from the abdominal cavity. This article aims to analyze the effects of peritoneal lavage in the reduction of postoperative shoulder pain. PATIENTS AND METHODS: 277 patients enrolled to undergo laparoscopic gynecologic surgery were included in the study. Women are randomized into two groups, according to the use or non-use of peritoneal lavage with saline solution at the end of laparoscopic gynecological major procedures. RESULTS: Data show that the peritoneal lavage can significantly reduce postoperative pain in the first 36 hours after surgery, as well as patients' requests for analgesics: during the first 3 postoperative days, requests for paracetamol were lower in the YW (Yes Washing) group than the NW (No Washing) group (77 vs. 101; p<0.05); similar results are obtained considering ketorolac administration (62 vs. 71; p<0.05). CONCLUSIONS: Peritoneal lavage after gynecological laparoscopic procedures may be effective in the reduction of postoperative pain and use of analgesics.

Hemorrhagic cystitis in pregnancy: Case report and review of the literature.

Hemorrhagic cystitis is generally a benign self-limited disorder, however there are some severe cases which are associated to a significant blood loss. The etiology may be either bacterial, viral or chemical in origin; though the cause is not identified in most of the cases. Immunocompromised patients or patients who have undergone chemotherapy or radiation constitute the highest risk group. There are only a few articles about hemorrhagic cystitis in pregnancy, frequently associated with preterm labor. We describe, for the first time in literature, one patient with a clinical status of hematuria in two consequent pregnancies, without any identified cause and a medical history negative for recurrent or hemorrhagic cystitis and we report an overview of literature concerning this topic.

Total rectosigmoidectomy versus partial rectal resection in primary debulking surgery for advanced ovarian cancer.

PURPOSE: To compare in a sample of Italian patients intraoperative, perioperative complications, Quality of Life (QoL), recurrence rate and overall survival of advanced ovarian cancer (AOC) patients according to the type of surgery performed on sigma-rectum, total rectosigmoid resection (TRR) versus partial rectosigmoid resection (PRR). METHODS: From May 2004 to May 2010, consecutive patients affected by epithelial AOC (FIGO Stage III-IV) were assessed for this prospective case-control study, According to the type of colorectal surgery performed to approach rectosigmoid involvement, patients were allocated into Group A (TRR) and Group B (PRR). PRR was performed when the complete removal of disease led to a laceration <30-40% of intestinal wall circumference. RESULTS: 82 and 72 patients were included in Group A and Group B respectively. Surgical outcomes were statistically similar except hospital stay which was significantly lower in the PRR group. There was not a statistically significant difference as regarding intra-operative, perioperative and postoperative complications, even if a higher rate of major complications were recorded in TRR. An improvement in QoL's scores has been recorded in PRR's group. There was not a statistically difference concerning the optimal debulking rate (92% and 96% respectively) and 5-year Overall Survival (48% and 52% respectively). CONCLUSIONS: PRR seems to be feasible in over 40% of patients with advanced ovarian cancer and recto-sigmoid colon involvement. It is related to higher QoL and can be easily performed, without jeopardizing surgical radicality, in those cases in which conservative surgery at intestinal tract does not compromise residual tumor.

Secondary Cytoreduction in Platinum-Resistant Recurrent Ovarian Cancer: A Single-Institution Experience.

BACKGROUND: The purpose of this study was to observe the role of secondary cytoreductive surgery in platinum-resistant recurrent ovarian cancer (OC) patients. METHODS: We collected data of patients affected by recurrent OC treated between 1995 and 2013. Inclusion criteria were: invasive epithelial OC histologically documented, cytoreductive surgery and platinum-based chemotherapy at first-line treatment with evidence of complete response to treatment, disease-free interval <6 months, and no concomitant neoplasia. Patients considered susceptible of cytoreductive surgery (group A) were compared with a historical series of patients with similar characteristics but not eligible for surgery (group B). RESULTS: Of 122 platinum-resistant patients, 18 met the inclusion criteria for the study and were enrolled. They were compared with a historical series of 18 patients not surgically treated with analogous clinical and pathological features. The most frequent sites of relapse included pelvic and aortic lymph nodes (39 %), peritoneum (33 %), bowel (28 %), and pelvis (22 %). A low rate of intraoperative and postoperative complications was reported. No deaths were recorded. Overall survival was significantly longer in cytoreductive group when compared with the control group (P = 0.035). Median overall survival was 44 months. Estimated 5-year overall survival rates were 57 versus 23.5 % for groups A and B, respectively. CONCLUSIONS: Surgery could represent a useful adjunct to chemotherapy in the management of platinum-resistant recurrent OC patients, carefully selected, in highly selected centers. Larger prospective trials are needed to further confirm our experience.

[Evolution of electronic fetal monitoring in labor]. / Evoluzione della cardiotocografia fetale in travaglio.

Intrapartum fetal hypoxia remains an important cause of neonatal permanent handicap and death, and in many cases it is related to lack of optimal fetal surveillance. In the last 40 years cardiotocography (CTG) has been routinely used for fetal monitoring yet this technique lacks reproducibility and its interpretation by healthcare professionals remains an important variable. Indeed, this technology not only does not improve clinically important outcomes, but also, on the contrary, leads to an increase in the number of caesarean sections carried out. Recent research has focused the attention on specific components of electronic fetal monitoring (EFM) tracings, such as ST-segment analysis (STAN) or fetal pulse oximetry (FPO). Fetal ST-segment analysis and pulse oximetry provide important parameters when used in addition to CTG, but their combined use obviously does not eliminate CTG interpretation limits. Although continuous electronic fetal monitoring is now ubiquitously utilized in modern practice, risks and benefits associated with its use are worth analysing. The analysis of the research and clinical practices carried out in the past several decades may provide useful insights into the current use of electronic fetal monitoring and new system associated procedures (STAN and FPO), which have influenced what has now become a routine modern obstetric practice.

Relaxant effect of proton pump inhibitors on in vitro myometrium from pregnant women.

AIM: In this study we investigate in in vitro myometrial tissue samples of pregnant women: (a) the effects of proton pomp inhibitors (PPIs) (omeprazole, esomeprazole, pantoprazole, lansoprazole and rabeprazole) on spontaneous contractions; (b) the muscle-relaxant efficacy of the most active PPI considered (pantoprazole) in comparison with that of other known tocolytics (nifedipine, atosiban, MgSO4, isoxsuprine); (c) the effect of pantoprazole on contractions induced by calcium (Ca(++)), KCl, oxytocin and prostaglandin (PGE2); (d) the possible mediators of pantoprazole relaxant effect. METHODS: Organ bath studies were performed on myometrial tissue samples (40×10×10 mm) from pregnant women (38-42 weeks of gestational age) undergoing elective caesarian section. RESULTS: All the PPIs studied reduce the spontaneous contraction of the myometrial smooth muscle. Pantoprazole is the most effective and most potent inhibitor among those analyzed. Pantoprazole also reduces the contractions induced by Ca(++), KCl, oxytocin and PGE2. Neither NO, nor PGs, or the activation of Ca(++)-dependent K(+) currents mediate the muscle-relaxant effect of this PPI. CONCLUSION: These data, together with the fact that PPIs almost do not present side effects, suggest that these drugs can offer new therapeutic strategies for preterm delivery. Undoubtedly, further investigations and clinical studies are necessary before adding PPIs to the list of drugs available for the treatment of preterm delivery.

Systematic lymphadenectomy in ovarian cancer at second-look surgery: a randomised clinical trial.

BACKGROUND: The role of systematic aortic and pelvic lymphadenectomy (SAPL) at second-look surgery in early stage or optimally debulked advanced ovarian cancer is unclear and never addressed by randomised studies. METHODS: From January 1991 through May 2001, 308 patients with the International Federation of Gynaecology and Obstetrics stage IA-IV epithelial ovarian carcinoma were randomly assigned to undergo SAPL (n=158) or resection of bulky nodes only (n=150). Primary end point was overall survival (OS). RESULTS: The median operating time, blood loss, percentage of patients requiring blood transfusions and hospital stay were higher in the SAPL than in the control arm (P<0.001). The median number of resected nodes and the percentage of women with nodal metastases were higher in the SAPL arm as well (44% vs 8%, P<0.001 and 24.2% vs 13.3%, P:0.02). After a median follow-up of 111 months, 171 events (i.e., recurrences or deaths) were observed, and 124 patients had died. Sites of first recurrences were similar in both arms. The adjusted risk for progression and death were not statistically different (hazard ratio (HR) for progression=1.18, 95% confidence interval (CI)=0.87-1.59; P=0.29; 5-year progression-free survival (PFS)=40.9% and 53.8%; HR for death=1.04, 95% CI=0.733-1.49; P=0.81; 5-year OS=63.5% and 67.4%, in the SAPL and in the control arm, respectively). CONCLUSION: SAPL in second-look surgery for advanced ovarian cancer did not improve PFS and OS.

[Prevention of postoperative abdominal adhesions in gynecological surgery. Consensus paper of an Italian gynecologists' task force on adhesions]. / Aderenze addominali postoperatorie e loro prevenzione in chirurgia ginecologica. Documento di consenso si una "task force" di ginecologi italiani sulle aderenze.

Adhesions are the most frequent complication of abdominopelvic surgery, causing important short- and long-term problems, including infertility, chronic pelvic pain and a lifetime risk of small bowel obstruction. They also complicate future surgery with considerable morbidity and expense, and an important mortality risk. They pose serious quality of life issues for many patients with associated social and healthcare costs. Despite advances in surgical techniques, the healthcare burden of adhesion-related complications has not changed in recent years. Adhesiolysis remains the main treatment although adhesions reform in most patients. There is rising evidence, however, that surgeons can take important steps to reduce the impact of adhesions. A task force of Italian gynecologists with a specialist interest in adhesions having reviewed the current evidence on adhesions and considered the opportunities to reduce adhesions in Italy, have approved a collective consensus position. This consensus paper provides a comprehensive overview of adhesions and their consequences and practical proposals for actions that gynecological surgeons in Italy should take. As well as improvements in surgical technique, developments in adhesion-reduction strategies and new agents offer a realistic possibility of reducing adhesion formation and improving outcomes for patients. They should be adopted particularly in high risk surgery and in patients with adhesiogenic conditions. Patients also need to be better informed of the risks of adhesions.

[Tubo-peritoneal factor of infertility: diagnosis and treatment]. / Diagnosi e terapia del fattore tubo-peritoneale di sterilità.

Infertility, defined as the inability to conceive despite regular unprotected sexual intercourse over 12 years, affects approximately 10% of the fertile population. The commonest cause of tubal damage is pelvic inflammatory disease (PID), which in the developed world is caused mainly by Chlamydia trachomatis infection. The incidence of tubal damage after one episode of pelvic infection is approximately 12%, 23% after two episodes and 54% after three episodes. Other causes of tubal damage include postsurgical adhesions or endometriosis. Tubal patency can be diagnosed by hysterosalpingography (HSG) or laparoscopy with chromopertubation. Surgery represents the best therapeutic approach for tubal pathology, with a term pregnancy rate of 70% after surgery in selected patients, while the latest results in Italy of assisted reproductive technology (ART) report a live birth rate per cycle of 13.8%. In conclusion, tubal reconstructive surgery remains an important option for many couples and surgery should be the fi rst line approach for a correct diagnosis and treatment of tubal infertility.

[The role of laparoscopy in ovarian carcinoma]. / Il ruolo della laparoscopia nel carcinoma ovarico.

The role of minimally invasive surgery in the management of gynecologic cancers is continuously expanding. Although few trials have focused on the safety of laparoscopy in oncology, laparoscopy is now widely used for most gynecological malignancies. Laparoscopy is widely used to manage benign ovarian masses, but its role in managing ovarian cancer still needs to be defined. The role of laparoscopy in ovarian cancer surgery may be divided into three following categories: 1) laparoscopic staging of apparent early ovarian cancer; 2) laparoscopic assessment of disease extent and potential for resectability; 3) laparoscopic reassessment, or second-look operation, or rule out recurrence. Laparoscopic approach has shown several advantages like a reduction in operating time, blood loss, hospital stay, and total hospital charges. The limitations of laparoscopic practice include inadequate port-site metastasis, tumour dissemination due to cyst rupture and incomplete staging. In addition, there were limitations in performing extensive laparoscopic sampling of areas of tumor persistence including retroperitoneal lymph nodes. In literature there are no randomized studies assessing the use of laparoscopy in the management of ovarian cancer. Moreover, most of the studies in literature comparing laparoscopy and laparotomy are carried out by surgeons specialized in one of two approaches, so that the results can not be compared.

[Prevention of postoperative adhesions]. / Aderenze postchirurgiche: attuali strategie preventive.

Postoperative adhesions represent a common consequence in patients who underwent abdominal or pelvic surgery. Such adhesions can be asymptomatic, but they can cause complications such as chronic abdomino-pelvic pain, secondary infertility, an increase in bowel obstruction risk and more complexity for future surgery, including longer surgery times and an increase in morbidity. Normally, adhesions appear after offences against the peritoneum, causing flogosys, and develop both in new sites, previously not involved, and in sites already interested in adhesiolysis. Previous laparotomy is an important risk factor, as after laparatomy a minimum of 93% of patients present adhesions during a following surgery. Furthermore, the rate of recurrence after adhesiolysis is 85%. Among several strategies employed, valid prevention methods are: using minimally invasive surgery techniques, reducing the incision area, containing tissue dehydration during surgery and an accurate hemostasis. Also, for preventing and reducing adhesions, the usage of NSAIDs, fibrinolytics and anticoagulants, as well as the application of substances acting as a physical barrier, have been proposed. Recently, crystalloid solutions have been introduced, using the hydro-flotation principle for intraperitoneal organs. This research aims to analyze causes and epidemiology for postoperative adhesions, with particular regard to gynecological operations and to describe and compare the means available to prevent them.

[Use of bulking agents in urinary incontinece]. / L'utilizzo dei bulking agents nel trattamento dell'incontinenza urinaria.

Urinary incontinence consist in voluntary urine leakage. Female affected in the world are about 200 thousand. Urinary incontinence affect severely women quality of life. There are different kinds of urinary incontinence that can be treated in different ways. We can use pelvic floor rehabilitation, drug therapy, invasive and non-invasive surgical treatment. Different treatments are used for different incontinence types. Periurethral injection is the most common procedure between non-invasive surgery. The most recent bulking agents occasionally determine severe adverse reaction or complication. Frequently we can have just pain during injection and a temporary urine retention. During the latest years we used a lot of bulking agents: bovine collagen, autologous fat, carbon particles, macroplastique, calcium hydroxylapatite, ethylene vinyl alcohol copolymer, dextranomer. Urethral injection have success in 40-90%. We can assert that macroplastique is the most efficacy and safe on the basis of literature data and of our experience data. This surgical procedure, in fact, has good percentage of success in accurately selected patients. In our experience Macroplastique can also be used in oncological patients, in elderly women, in patients with important comorbidity and with high surgical risk with good objective and subjective results.

Bulky lymph node resection in patients with recurrent epithelial ovarian cancer: impact of surgery.

The aim of this study was to evaluate the role of systematic lymphadenectomy, feasibility, complications rate, and outcome in epithelial ovarian cancer (EOC) patients with recurrent bulky lymph node disease. A prospective observational study of EOC patients with pelvic/aortic lymph node relapse was conducted between January 1995 and June 2005. After a clinical and laparoscopic staging, secondary cytoreduction, including systematic lymphadenectomy, were performed. The eligibility criteria were as follows: disease-free interval > or =6 months, radiographic finding suggestive of bulky lymph node recurrence, and patients' consent to be treated with chemotherapy. Forty-eight EOC patients with lymph node relapse were recruited. Twenty-nine patients were amenable to cytoreductive surgery. Postoperatively, all patients received adjuvant treatment. The median numbers of resected aortic and pelvic nodes were 15 (2-32) and 17 (8-47), respectively. The median numbers of resected aortic and pelvic positive lymph nodes were 4 (1-18) and 3 (1-17), respectively. The mean size of bulky nodes was 3.3 cm. Four patients (14%) experienced one severe complication. No treatment-related deaths were observed. After a median follow-up of 26 months, among cytoreduced patients, 18 women were alive with no evidence of disease, nine were alive with disease. Among the 11 patients not amenable to surgery, five women were alive with persistent disease, six patients died of disease, at a median follow-up of 18 months. Estimated 5-year overall survival and disease-free interval for operated women were 87% and 31%, respectively. In conclusion, patients with bulky lymph node relapse can benefit from systematic lymphadenectomy in terms of survival. The procedure is feasible with an acceptable morbidity rate.

Hemoglobin variation and blood transfusion rates in patients affected by locally advanced cervical cancer undergoing neo-adjuvant chemotherapy followed by radical surgery: the role of erythropoietic growth factors.

BACKGROUND: The objectives of the present study were to evaluate hemoglobin levels and consequent clinical behaviors related to anemia developed in patients affected by locally advanced cervical cancer treated with neo-adjuvant chemotherapy in the last decade and to evaluate the impact that the introduction of erythropoietic growth factors had in the clinical practice. PATIENTS AND METHODS: Blood chemistries, prospectively recorded from 98 cervical cancer patients, treated with neo-adjuvant chemotherapy and, if necessary, erythropoietic growth factors, were compared with matched historical controls before the introduction of growth factors in clinical practice. RESULTS: Hemoglobin level in the study group did not differ significantly during chemotherapy. At the third cycle of chemotherapy and at the end of chemotherapy, hemoglobin level was significantly higher in the study group compared with the control group. Transfusion rates in the study group were significantly lower. The analysis within the study group revealed that hemoglobin level in patients who suffer at diagnosis from anemia tends to increase whereas hemoglobin level in nonanemic patients tends to decrease. CONCLUSIONS: Erythropoietic growth factors increase hemoglobin level and reduce blood transfusions in cervical cancer patients undergoing neo-adjuvant chemotherapy followed by radical surgery. An appropriate autologous blood donation program can noticeably reduce homologous blood transfusions.

Liposome-encapsulated doxorubicin citrate in previously treated recurrent/metastatic gynecological malignancies.

The aim of this study was to evaluate the safety and efficacy of liposome-encapsulated doxorubicin citrate (LEDC) in patients affected by recurrent/metastatic gynecological malignancies scheduled for palliative chemotherapy. Inclusion criteria were proven recurrent/advanced gynecological neoplasms, measurable/assessable disease, adequate organ function, left ventricular ejection fraction >50% as determined by echocardiography, informed consent. LEDC was administered intravenously over 1 h at the dose of either 75 mg/m(2) or 60 mg/m(2) (every 3 weeks until disease progression or toxicity prohibiting further therapy). From May 2003 to September 2005, 36 patients were enrolled. Primary disease was ovarian, endometrial, and cervical cancers in 15 (42%), 11 (30%), and 10 (28%) patients, respectively. LEDC was employed as third- or fourth-line chemotherapy in 25 (70%) and 11 (30%) patients, respectively. The median number of courses of LEDC received was 3 (range 2-9). Six patients (17%) achieved a partial response to treatment lasting 27 weeks and 10 patients (28%) experienced stable disease lasting 18 weeks. The predominant toxicity was hematological, especially neutropenia. Among patients receiving a dose of 75 mg/m(2), two (11%) suspended therapy for febrile neutropenia, and nine (50%) required a dose reduction of 25%. As a result, the next 18 patients were treated at a reduced dose (60 mg/m(2)) of LEDC. Severe neutropenia (G3-G4) was significantly less common in this group (61% versus 22%; P= 0.04). LEDC has shown antineoplastic activity in previously treated recurrent/metastatic gynecological cancer patients and the toxicity profile could be considered acceptable at a 60 mg/m(2) dosage.

[Up-date on cytoreductive surgery in the management of advanced ovarian cancer]. / Aggiornamenti in tema di citoriduzione nel trattamento del carcinoma ovarico avanzato.

Epithelial ovarian cancer represents the most aggressive neoplasm of women genital apparatus with a total 5-year survival rate ranging from 17% to 35% if the disease is in the metastatic phase. Its aggressiveness derives from the fact that it is an asymptomatic disease until it spreads in abdominal cavity. Therefore, in 70% of the cases, the diagnosis is done when tumor is already in advanced phase (Stage FIGO IIB-IV). Data from international literature suggest that standard treatment for advanced ovarian cancer is optimal cytoreductive surgery with adjuvant chemotherapy platinum-based. However, in the last decades, many authors have described the enthusiastic results of neoadjuvant chemotherapy and interval debulking surgery. Griffiths, first, underlined the importance of residual mass after cytoreductive surgery as a prognostic factor. Currently, cytoreduction is defined optimal when residual mass is microscopical or absent. Nevertheless, surgery for ovarian cancer turns out to be a particularly aggressive surgery that needs an operator's remarkable technical ability and a cultural Background: Many studies demonstrated that the frequency of feasibility of optimal cytoreductive surgery also varies within the gynecologic oncology specialized centers. During the last few years, new technologies (such as Cavitron Ultrasonic Surgical Aspirator, CUSA, and argon's coagulator) and new surgical techniques have been introduced. Ovarian cancer turns out to be a particularly chemosensitive tumor. Its responsiveness has been the object of numerous studies and protocols in literature, such as European Organisation of Research and Treatment of Cancer (EORTC) and Gynecologic Oncology Group (GOG) trials.

Randomised study of systematic lymphadenectomy in patients with epithelial ovarian cancer macroscopically confined to the pelvis.

No randomised trials have addressed the value of systematic aortic and pelvic lymphadenectomy (SL) in ovarian cancer macroscopically confined to the pelvis. This study was conducted to investigate the role of SL compared with lymph nodes sampling (CONTROL) in the management of early stage ovarian cancer. A total of 268 eligible patients with macroscopically intrapelvic ovarian carcinoma were randomised to SL (N=138) or CONTROL (N=130). The primary objective was to compare the proportion of patients with retroperitoneal nodal involvement between the two groups. Median operating time was longer and more patients required blood transfusions in the SL arm than the CONTROL arm (240 vs 150 min, P<0.001, and 36 vs 22%, P=0.012, respectively). More patients in the SL group had positive nodes at histologic examination than patients on CONTROL (9 vs 22%, P=0.007). Postoperative chemotherapy was delivered in 66% and 51% of patients with negative nodes on CONTROL and SL, respectively (P=0.03). At a median follow-up of 87.8 months, the adjusted risks for progression (hazard ratio [HR]=0.72, 95%CI=0.46-1.21, P=0.16) and death (HR=0.85, 95%CI=0.49-1.47, P=0.56) were lower, but not statistically significant, in the SL than the CONTROL arm. Five-year progression-free survival was 71.3 and 78.3% (difference=7.0%, 95% CI=-3.4-14.3%) and 5-year overall survival was 81.3 and 84.2% (difference=2.9%, 95% CI=-7.0-9.2%) respectively for CONTROL and SL. SL detects a higher proportion of patients with metastatic lymph nodes. This trial may have lacked power to exclude clinically important effects of SL on progression free and overall survival.