Utility of Three-Dimensional Ultrasonography to Assess the Position of Essure Tubal Occlusion Device and Its Complications.

BACKGROUND: To determine the utility of three-dimensional (3D) sonography to control the position of hysteroscopic sterilizing device compared to hysterosalpingography (HSG). METHODS: A prospective observational study was carried out on 139 patients who underwent hysteroscopic tubal occlusion method between February 2012 and May 2013. Patients underwent 3D ultrasound scan to control device positioning, and they also underwent HSG as an additional control method. Comparison between both methods was carried out. RESULTS: In all, 17 (12.2%) devices were inserted due to a hydrosalpinx and 122 (87.8%) due to sterilization purposes. In 124 (89.2%) cases, sonography correlated completely to HSG findings. Sonography-positive predictive value was 89.5% to detect correct device positioning. Just 4 (2.8%) patients did not present complete tubal occlusion 3 months after device insertion; one of them presented device expulsion, 2 of them presented previous hydrosalpinx (tubal occlusion was confirmed after 6 months), and the last case rejected to undergo further controls but device seem to be effective. CONCLUSIONS: 3D sonography seems to be effective for the control of sterilization device positioning, but it also detects insertion complications and device migration. Further studies would be required to assess our findings and the role of sonography in case of hydrosalpinx.

Novel Technique for Contained Power Morcellation through Umbilicus with Insufflated Bag.

In April 2014, the US Food and Drug Administration published a safety communication warning of the risk of an unsuspected uterine sarcoma being morcellated during a laparoscopic procedure and therefore advising against the use of power morcellation. These statements have encouraged the scientific community to look for new techniques that allows performing this procedure in a safer way, decreasing the risk of malignant dissemination thorough the abdominal cavity. We describe a new technique for power morcellation using a plastic bag through umbilicus using a latex glove and skin retractor as a single port device. This new procedure was performed in 4 women diagnosed with myomatous uterus. Median age was 40.5 years. No intraoperative complications, conversion to laparotomy or bag rupture occurred. Median surgical time was 195 min and median morcellation time was 48 min. Median in-hospital stay was 4.5 days. This new technique could be an acceptable and feasible alternative for specimen delivery during laparoscopic hysterectomy and myomectomy. However, it is still necessary to increase the number of procedures to assess its safety in case of uterine sarcoma. The video and supplemental contents demonstrate the safety and feasibility of the technique.

The role of surgery in advanced epithelial ovarian cancer.

Nowadays, the standard management of advanced epithelial ovarian cancer is correct surgical staging and optimal tumour cytoreduction followed by platinum and taxane-based chemotherapy. Standard surgical staging consists of peritoneal washings, total hysterectomy, and bilateral salpingo-oophorectomy, inspection of all abdominal organs and the peritoneal surface, biopsies of suspicious areas or randomised biopsies if they are not present, omentectomy and para-aortic lymphadenectomy. After this complete surgical staging, the International Federation of Gynaecology and Obstetrics (FIGO) staging system for ovarian cancer is applied to determine the management and prognosis of the patient. Complete tumour cytoreduction has shown an improvement in survival. There are some criteria to predict cytoreduction outcomes based on serum biomarkers levels, preoperative imaging techniques, and laparoscopic-based scores. Optimised patient selection for primary cytoreduction would determine patients who could benefit from an optimal cytoreduction and might benefit from interval surgery. The administration of intraperitoneal chemotherapy after debulking surgery has shown an increase in progression-free survival and overall survival, especially in patients with no residual disease after surgery. It is considered that 3-17% of all epithelial ovarian carcinoma (EOC) occur in young women that have not fulfilled their reproductive desires. In these patients, fertility-sparing surgery is a worthy option in early ovarian cancer.

Novel technique for the complete staging of endometrial cancer by single-port laparoscopy.

OBJECTIVE: Our aim was to evaluate the feasibility of a novel technique using single-port laparoscopy for the complete surgical staging of endometrial cancer. METHODS: Total hysterectomy, bilateral salpingo-oophorectomy, pelvic lymphadenectomy and para-aortic lymphadenectomy was performed using a single-port device in two steps: first, a retroperitoneal para-aortic dissection was conducted, followed by a transperitoneal pelvic lymphadenectomy and a total hysterectomy. Conventional laparoscopic instruments were used in all cases. Perioperative details were collected. RESULTS: Four consecutive patients with endometrial cancer underwent single-port laparoscopic staging procedure. All cases were high-risk endometrial cancers (two FIGO stage IA and two IB). Histologic types included three adenocarcinomas and one carcinosarcoma. The median operating time was 280min (ranged 240-320min), and the median length of stay was 3.5days (ranged 3-6days). No complications or conversion to conventional multiport laparoscopy were reported. CONCLUSIONS: Single-port laparoscopic surgical staging for endometrial cancer is a feasible procedure, even when the procedure included a para-aortic lymph node dissection.

Risk of bleeding with dabigatran in atrial fibrillation.

IMPORTANCE: It remains unclear whether dabigatran etexilate mesylate is associated with higher risk of bleeding than warfarin sodium in real-world clinical practice. OBJECTIVE: To compare the risk of bleeding associated with dabigatran and warfarin using Medicare data. DESIGN, SETTING, AND PARTICIPANTS: In this retrospective cohort study, we used pharmacy and medical claims in 2010 to 2011 from a 5% random sample of Medicare beneficiaries. We identified participants as those newly diagnosed as having atrial fibrillation from October 1, 2010, through October 31, 2011, and who initiated dabigatran or warfarin treatment within 60 days of initial diagnosis. We followed up patients until discontinued use or switch of anticoagulants, death, or December 31, 2011. EXPOSURES: Dabigatran users (n = 1302) and warfarin users (n = 8102). MAIN OUTCOMES AND MEASURES: We identified any bleeding events and categorized them as major and minor bleeding by anatomical site. Major bleeding events included intracranial hemorrhage, hemoperitoneum, and inpatient or emergency department stays for hematuria, gastrointestinal, or other hemorrhage. We used a propensity score weighting mechanism to balance patient characteristics between 2 groups and Cox proportional hazards regression models to evaluate the risk of bleeding. We further examined the risk of bleeding for 4 subgroups of high-risk patients: those 75 years or older, African Americans, those with chronic kidney disease, and those with more than 7 concomitant comorbidities. RESULTS: Dabigatran was associated with a higher risk of bleeding relative to warfarin, with hazard ratios of 1.30 (95% CI, 1.20-1.41) for any bleeding event, 1.58 (95% CI, 1.36-1.83) for major bleeding, and 1.85 (95% CI, 1.64-2.07) for gastrointestinal bleeding. The risk of intracranial hemorrhage was higher among warfarin users, with a hazard ratio of 0.32 (95% CI, 0.20-0.50) for dabigatran compared with warfarin. Dabigatran was consistently associated with an increased risk of major bleeding and gastrointestinal hemorrhage for all subgroups analyzed. The risk of major bleeding among dabigatran users was especially high for African Americans and patients with chronic kidney disease. CONCLUSIONS AND RELEVANCE: Dabigatran was associated with a higher incidence of major bleeding (regardless of the anatomical site), a higher risk of gastrointestinal bleeding, but a lower risk of intracranial hemorrhage. Thus, dabigatran should be prescribed with caution, especially among high-risk patients.