Intestinal perforation in gynecologic oncology: do all patients benefit from surgical management?

OBJECTIVE: To identify those patients with gynecologic cancers and intestinal perforation in whom conservative management may be appropriate. METHODS: A retrospective review was performed of all gynecologic oncology patients with intestinal perforation at our institution between 1995 and 2011. The Kaplan-Meier method and Cox proportional hazards models were used to analyze factors influencing survival. RESULTS: Forty-three patients met the study criteria. The mean age was 59 years (range: 38-82 years). A large number of patients had peritoneal carcinomatosis and history of bowel obstruction. Surgery was performed in 28 patients, and 15 were managed conservatively. Overall mortality at 1, 3, 6, and 12 months was 26%, 40%, 47%, and 59%, respectively. Only cancer burden at the time of perforation was independently predictive of mortality. Patients with peritoneal carcinomatosis, distant metastasis, or both were at 42 times higher risk of death than those with no evidence of disease (95% CI: 3.28-639.83), and at 7 times higher risk of death than those with microscopic/localized disease (95% CI: 1.77-29.94). When adjusted for the extent of disease spread, management approach (conservative vs. surgical) was not a significant predictor of survival (p≥0.05). The length of hospital stay (19 days vs. 7 days) and the complication rate (75% vs. 26.7%) were significantly higher in the surgical group than in the non-surgical group (p<0.05). CONCLUSIONS: Patients who develop intestinal perforation in the setting of widely metastatic disease have a particularly poor prognosis. Aggressive surgical management is unlikely to benefit such patients and further impairs their quality of life.

Comparison of neonatal and maternal outcomes associated with head-pushing and head-pulling methods for impacted fetal head extraction during cesarean delivery.

OBJECTIVE: To compare the morbidity and mortality of 2 current techniques during cesarean delivery of an impacted fetal head. METHODS: In a comparative setting, 59 pregnant women with obstructed labor due to impacted fetal head were recruited. The patients were categorized into 2 groups according to method of extraction: the "push" group (n=30) and the "pull" group (n=29). Uterus relaxants were used before cesarean in all cases and the incision was higher and wider than routine. Maternal and neonatal morbidities were compared between the groups. RESULTS: Maternal complications in the push and pull groups were extension of the uterine incision (15 [50.0%] vs 5 [17.2%]); T or J incision (3 [10.0%] vs 4 [13.8%]); blood transfusion (3 [10.0%] vs 1 [3.4%]); wound infection (4 [13.3%] vs 1 [3.4%]); fever (16 [53.3%] vs 3 [10.3%]); and urinary tract infection (10 [33.3%] vs 0 [0.0%]). Incidences of extension of the uterine incision, fever, and urinary tract infection were significantly higher in the push group (P=0.008). CONCLUSION: Owing to a lower rate of abnormal incision and postpartum fever/infection with the pull method, this technique is preferable to the push method.

Therapeutic effects of biguanide vs. statin in polycystic ovary syndrome: a randomized clinical trial.

Various classes of medication are currently being used in Polycystic Ovary Syndrome (PCOS) patients including the biguanides and the statins. However, their efficacies are rarely compared. This study aimed to compare efficacy ofa biguanide and a statin in treating PCOS. In a randomized double-blind clinical trial, 400 women with PCOS were recruited within 15 months in Taleghani Hospital. They randomly received either a biguanide (metformin 500 mg three times daily) or a statin (simvastatin 20 mg daily) for three consecutive months. Changes of clinical and laboratory variables were compared. In the biguanide group the serum glucose status (abnormal fasting and non-fasting sugar and insulin levels and percentage of hyperinsulinemic cases) and menstrual abnormalities improved significantly after treatment (p < 0.05). In the statin group the lipid profile status (abnormal total cholesterol, high and low density lipoproteins), C-Reactive Protein (CRP), serum dehydroepiandrosterone sulfate, hyperinsulinemia, severity of acne and menstrual abnormalities improved significantly after treatment (p < 0.05). Comparing the two groups, the improvements in fasting blood sugar and serum insulin levels were significantly better in the biguanide group (p = 0.04 for both parameters); whereas the improvements in serum total cholesterol (p < 0.001), low density lipoprotein (p < 0.001), CRP (p < 0.001) and acne status (p = 0.04) were significantly superior in the statin receivers. Based on these results, each medication is only effective on some aspects of the disease. Overall, the simvastatin was superior to metformin with regard to the number of beneficial effects.