Pneumoperitoneum induced mesothelial cell changes in a laparoscopic mouse model.

BACKGROUND: CO2 pneumoperitoneum (PP) during laparoscopic surgery, can cause hypoxia and desiccation in the peritoneal mesothelial cell, resulting in a time-dependent retraction and bulging of these cells, an acute inflammatory reaction and enhanced adhesion formation. Since hypoxia is prevented by adding 4% of oxygen (O2) to the CO2 PP, the aim of this study was to evaluate the effect of adding 4% O2 to the CO2 PP on mesothelial cell morphology. METHODS: In a standardized laparoscopic mouse model (n=8 mice per group), a control group with a 30- or 60-min PP with humidified CO2 + 4% of O2 (groups I and II) was compared to a hypoxic group with 30- or 60-min humidified pure CO2 (groups III and IV) and a desiccation group with 60-min of dry CO2 PP (group V). The effect upon the peritoneum morphology was evaluated by scanning electron microscopy (SEM) of abdominal wall peritoneal biopsies. Biopsies, taken immediately (n=4) and 24 hrs (n=4) after surgery, were compared to a group without PP (group VI, n=4). SEM pictures were blindly scored for cell retraction, deletion of microvilli, fibrin deposition, holes in the epithelial layer and visibility of cell borders using a semi-quantitative scoring system. RESULTS: PP Hypoxia (CO2 PP) has a deleterious effect upon mesothelial morphology, immediately (holes: p= 0.04) and 24 hrs later (cell retraction: p=0.005; total score: p=0.03) . Desiccation has also a deleterious effect immediately (microvilli p=0.0090; fibrin deposition p=0.05) and 24 hrs after surgery (cell retraction: p=0.0036; holes: p=0.0004; microvilli: p< 0.0001, fibrin deposition: p=0.0225; borders: p=0.0007). This deleterious effect increases with duration of CO2 PP, affecting cell retraction (p=0.016), holes (p=0.0441), and the total score (p=0.0488). The addition of 4% of O2 to the CO2 PP failed to reach statistical significance. CONCLUSIONS: These data confirm that CO2 PP and dry gas have a deleterious effect on mesothelial cell morphology. Humidification of the insufflation gas reduces this deleterious effect. The hypothesis of a protective effect of adding O2 failed to reach significance.

Intra- and interobserver variability in nodule size of rectosigmoid endometriosis measured by two- and three-dimensional transvaginal sonography.

INTRODUCTION: The aim of the study was to assess the intra- and interobserver variability of two- and three-dimensional rectosigmoid nodule size measurements by transvaginal sonography in patients with rectosigmoid endometriosis. MATERIAL AND METHODS: Intra- and interobserver variability was assessed in 10 and 30 patients, respectively. Measurements in two dimensions were performed in real-time during the scan, and three-dimensional measurements of volume were done on a computer. Differences within and between observers were expressed in absolute units (mm) and percentage (%) of average nodule size. Coefficient of repeatability and Bland-Altman plots with limits of agreement were used to evaluate the intra- and interobserver variability. RESULTS: Intra- and interobserver variability in two-dimensional sonography ranged from 11 to 14 mm (46-51%) for length, 3 to 6 mm (32-57%) for depth and 5 to 9 mm (33-58%) for width of the nodule. Results of three-dimensional sonography, with assessment of nodule volume, showed intra- and interobserver variability 0.4 to 2.5 times the average nodule size. CONCLUSIONS: Measurements of rectosigmoid endometriosis nodule size with two- and three- dimensional transvaginal sonography were associated with large intra- and interobserver variability. These techniques should therefore be used with caution in clinical control and research of nodule growth.

Pelvic Pain and Quality of Life Before and After Laparoscopic Bowel Resection for Rectosigmoid Endometriosis: A Prospective, Observational Study.

BACKGROUND: Surgery for rectosigmoid endometriosis carries a substantial risk of short- and long-term complications, which has to be counterbalanced against the potential effect of the procedure. Prospective data are scarce in the field of deep infiltrating endometriosis surgery. OBJECTIVE: The study aimed to assess pelvic pain and quality of life before and after laparoscopic bowel resection for rectosigmoid endometriosis. DESIGN: The study involved prospectively collected data regarding pelvic pain and quality of life before and after surgery. SETTINGS: It was conducted at a tertiary endometriosis referral unit at Aarhus University Hospital. PATIENTS: A total of 175 women were included. INTERVENTION: Patients underwent laparoscopic bowel resection for endometriosis. MAIN OUTCOME MEASURES: Questionnaires for pain (Numerical Rating Scale) and quality of life (RAND Short Form-36) were answered before and 1 year after surgery. Data on analgesic and hormone treatment were collected. Preoperative and postoperative pelvic pain and quality-of-life scores were compared, and risk factors for improvement/worsening were identified. RESULTS: A total of 97.1% of the women completed the 1-year follow up. A significant decrease (p = 0.0001) was observed on all pelvic pain parameters. Most profound was the decrease in dyschezia. A significant improvement on all quality-of-life scores was observed (p = 0.0001). A surgical complication did not have a negative impact on outcome 1 year after surgery. The postoperative outcome was not related to the type of surgery. LIMITATIONS: This is an observational study without a control group. Risk factor data should be interpreted with caution, because the study was relatively underpowered for some of the rare outcomes. CONCLUSIONS: A significant and clinically relevant improvement in pelvic pain and quality of life 1 year after laparoscopic bowel resection for endometriosis was found. We strongly recommend surgery for rectosigmoid endometriosis that is unresponsive to conservative treatment. See Video Abstract at http://links.lww.com/DCR/A472.

Risk of bowel obstruction during in vitro fertilization treatment of patients with deep infiltrating endometriosis.

INTRODUCTION: Women with endometriosis often experience pain and infertility. Medical treatment interferes with the possibility of attaining pregnancy. For infertile women with endometriosis, surgery is a possible treatment, but with advanced disease there is an increased risk of serious complications. With only limited pain, women will often be referred for in vitro fertilization treatment instead. The disease is estrogen-dependent and during in vitro fertilization treatment the women could theoretically experience worsening of their symptoms. MATERIAL AND METHODS: The study is a retrospective cohort study of 76 women with bowel endometriosis who were treated conservatively and underwent in vitro fertilization treatment. RESULTS: Nine (11.8%) of the women experienced severe worsening of their bowel-related symptoms, including two patients presenting with colon ileus. One additional woman had no previous diagnosis of endometriosis before she presented with subocclusion of the bowel during in vitro fertilization. In all cases the in vitro fertilization treatment was stopped. CONCLUSIONS: Our study revealed that bowel endometriosis increases the risk of complications during in vitro fertilization treatment. This is in contrast to several publications. However, our study population is different due to the fact that none of these women had previous operations for bowel endometriosis. In all, 88% of the women completed fertility treatment without need for surgery.

Conservative approach to rectosigmoid endometriosis: a cohort study.

INTRODUCTION: The aim of the study was to assess the risk of surgery after initial conservative treatment of rectosigmoid endometriosis in relation to demographic data. MATERIAL AND METHODS: The study was conducted on the tertiary endometriosis referral unit, Aarhus University Hospital. Medical records, from patients seen from January 2009 onwards with a diagnosis of rectosigmoid endometriosis and more than 6 months' follow up were audited. Demographic data, results of magnetic resonance imaging and time to secondary surgery for rectosigmoid endometriosis were registered. RESULTS: Data on 238 patients diagnosed with rectosigmoid endometriosis were included. In all, 78 (32.8%) patients had primary surgery, 27 (11.3%) had secondary surgery and 133 (55.9%) continued conservative treatment throughout the observation period. Patients who underwent primary or secondary surgery were younger than patients continuing conservative treatment. CONCLUSIONS: In a tertiary referral center where about half of patients with rectosigmoid endometriosis were scheduled for conservative treatment, more than 80% of these avoided surgery.

Diagnostic Value of Serial Measurement of C-Reactive Protein in the Detection of a Surgical Complication after Laparoscopic Bowel Resection for Endometriosis.

AIMS: The study aimed to assess the diagnostic value of serial monitoring of biochemical inflammatory markers (C-reactive protein (CRP) and white blood cell (WBC) count) in the postoperative diagnosis of anastomotic leakage or ureteral injury after bowel resection for deep infiltrating endometriosis. METHODS: This is a review of prospectively collected data from 217 patients who underwent laparoscopic bowel resection for endometriosis from January 2009 to April 2015. Patients with an anastomotic leakage or ureteral injury were identified and classified. RESULTS: The frequency of anastomotic leakage requiring reoperation was 8.3%. The frequency of ureteral injury was 4.6%. Median time to diagnosis was 6 days for anastomotic leakage and 8 days for ureteral injury. The daily mean values of serum CRP were significantly higher in patients with a surgical complication starting at the second postoperative day (POD 2, p = 0.004). WBC was significantly higher (p < 0.05) on POD 2 and 3 in patients with a surgical complication. A decrease in CRP from POD 1 to 3 predicted an uncomplicated course in 92.1% of the cases. CONCLUSION: A decrease in CRP from POD 1 to 3 was an indicator of uncomplicated subsequent postoperative course. The test is recommended when early discharge after rectal resection for deep infiltrating endometriosis is considered.

[Ultrasound scan did not locate misplaced intrauterine devices].

One of the rare but serious complications of intrauterine contraception is perforation of the uterine wall at insertion. We present two cases where intrauterine devices went missing. In both cases abdominal and vaginal ultrasound scan was performed to locate the intrauterine device. They were not found and doctors concluded that the intrauterine devices were lost by expulsion. One intrauterine device came out of the rectum by itself; the other was found and removed from inside the abdomen at laparoscopy. An X-ray examination should have been done before the conclusion of expulsion.

Combined oral contraception and obesity are strong predictors of low-grade inflammation in healthy individuals: results from the Danish Blood Donor Study (DBDS).

BACKGROUND: C-reactive protein (CRP) is a well-established marker of inflammation. The level of CRP is affected by several lifestyle factors. A slightly increased CRP level, also known as low-grade inflammation (LGI), is associated with increased risk of several diseases, especially cardiovascular disease. The aim of this study was to identify predictors of increased CRP levels in healthy individuals. We therefore assessed CRP in a large cohort of blood donors. METHODS: We measured plasma CRP levels in 15,684 participants from the Danish Blood Donor Study. CRP was measured by a commercial assay. Furthermore, all participants completed a standard questionnaire on smoking status, alcohol consumption, physical activity, diet, and various body measurements. Female participants also reported the use of contraception, childbirth, and menopausal status. The relationship between LGI (defined here as a plasma CRP level between 3 mg/L and 10 mg/L) and predictors was explored by multivariable logistic regression analysis. Results were presented as odds ratios (OR) with 95% confidence intervals (CI). RESULTS: We found LGI in a total of 1,561 (10.0%) participants. LGI was more frequent in women using combined oral contraception (OC) (29.9%) than in men (6.1%) and women not using OC (7.9%). Among premenopausal women, OC was the strongest predictor of LGI (odds ratio = 8.98, p<0.001). Additionally, body mass index (BMI) and waist circumference were positively associated with LGI. CONCLUSION: High BMI and abdominal obesity strongly predicted LGI among healthy individuals. However, the most striking finding was the high prevalence of LGI among premenopausal women who used combined oral contraception. Although the significance of CRP as a marker of inflammation is well known, the role of CRP in pathogenesis is still uncertain. The impact of oral contraception on CRP levels should nevertheless be considered when CRP is used in risk assessment.

Feasibility and clinical effects of laparoscopic abdominal cerclage: an observational study.

OBJECTIVE: To evaluate the effect of laparoscopic abdominal cerclage performed as an interval procedure in non-pregnant women at high risk of second trimester spontaneous abortion and early preterm birth. DESIGN: Observational study. SAMPLE: Fifty-two consecutive patients at high risk of preterm birth. SETTING: Department of Obstetrics and Gynecology, Aarhus University Hospital. METHODS: Patients were registered prospectively. Indications for surgery included classical cervical insufficiency, preterm premature rupture of membranes (PPROM) or two conizations/cervical amputation. Outcome of subsequent pregnancies was registered. MAIN OUTCOME MEASURES: Gestational age in subsequent pregnancies. RESULTS: No operative or postoperative complications were observed. A total of 45 pregnancies were registered during the observation period. Among 36 pregnancies lasting beyond the 16th week of gestation, 30 women (83.3%) gave birth by cesarean section after 36 weeks of gestation and the overall mean gestational age was 37.4 weeks compared with a mean gestational age of 25.2 weeks of the pregnancies prior to the cerclage. The cesarean sections were uncomplicated in all but one patient, where a re-laparotomy was needed six hours later due to atonic postpartum hemorrhage without evident bleeding through the cervix. CONCLUSION: Laparoscopic abdominal cerclage is a feasible and safe procedure. Obstetrical outcomes are encouraging but prospective studies are needed to define the effectiveness of the laparoscopic cerclage compared with the traditional transvaginal approach.

Association of interleukin--10 promoter polymorphism and endometriosis.

PROBLEM: inflammatory processes are believed to play an important role in the pathogenesis of endometriosis. Interleukin-10 (IL-10) is an important immunoregulatory cytokine. The biological actions are mainly inhibitory including inactivation of macrophages and inhibition of pro-inflammatory cytokines. Twin and family studies have shown that between 50 and 75% of the observed variability of IL-10 secretion was explained by genetic factors. Several single nucleotide polymorphisms (SNPs) in the promoter region of IL-10 have been described, but the most investigated are located at positions −1082, −819 and −592 of the transcriptional start site. METHOD OF STUDY: three SNPs in the promoter region of IL-10 (−1082)G>A, (−819)C>T and (−592)C>A were examined in 100 Danish patients with endometriosis and 358 healthy Danish blood donors, and haplotype associations were tested. RESULTS: we observed no strong single IL-10 marker effects and no single haplotype showed significant association. However, the ACC/ACC genotype showed a significant association because this genotype was significantly higher among patients with endometriosis than in healthy controls [OR = 3.55 (CI = 1.42­18.92); P = 0.006]. CONCLUSION: our results suggest that the IL-10 ACC/ACC genotype, which is known to be a 'low-producer' of IL-10, is associated with endometriosis.

Risk prediction in acute coronary syndrome from serial in-hospital measurements of N-terminal pro-B-type natriuretic peptide.

UNLABELLED: There is limited information about the in-hospital plasma profile of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in patients with non-ST-elevation acute coronary syndrome (NSTACS) and furthermore, the prognostic influence of the timing of NT-proBNP measurements in NSTACS is unsettled. These subject matters are elucidated in this study composed of 455 patients with NSTACS (symptoms <24 h). NT-proBNP was measured at 0, 6, 12, 24, 36, 48, 72 and 96 h following admission. Any death was registered at follow-up (median: 2.3 years). The study demonstrated a monophasic profile of the plasma NT-proBNP values, reaching a maximum at 6 hours, and it showed an independent prognostic significance of NT-proBNP irrespective of the sampling time. Risk prediction by NT-proBNP was improved by combining the baseline measurement and one value taken between 24 and 96 h (at 48 h, P<0.001). No additional prognostic information was provided by including more than one late in-hospital NT-proBNP value. CONCLUSIONS: The in-hospital NT-proBNP measurements exhibit a monophasic profile in patients with NSTACS and these values provide independent prognostic information as regards mortality irrespective of the sampling time. Moreover, risk prediction of NT-proBNP is strengthened by combining the admission measurement with an additional value during the hospitalization.