Migration of an ingested fishbone to the uterine wall: A case report.

This paper reports the first case of the removal of an ingested fishbone from the uterus. A 77-year-old woman presented with a 3-day history of lower abdominal pain. An abscess-like lesion in the posterior wall of the uterus was revealed by transvaginal ultrasonography and pelvic magnetic resonance imaging. Moreover, a curvilinear calcium density in the anterior uterine wall was revealed by abdominal computed tomography. A recto-sigmoidal perforation and uterine abscess were suspected. Thus, hysteroscopic drainage of the abscess was performed. Hysteroscopy revealed a fishbone partially embedded in the myometrium. Its removal resulted in full recovery. This study believed that adhesions between the uterus and rectosigmoid colon after partial gastrectomy for gastric cancer may have limited abdominal symptoms by limiting the leakage of intestinal fluids. Although rare, it should be considered that migration of a fishbone into the uterus could occur.

Hypochlorous acid water prevents postoperative intrauterine infection after microwave endometrial ablation.

AIM: We investigated the effects of uterine cavity lavage using hypochlorous acid water (HClO) on preventing postoperative intrauterine infection after microwave endometrial ablation (MEA). METHODS: Four hundred and eleven consecutive patients were enrolled in this study. The patients were divided into two groups: 214 cases in 2014-2016 with disinfection using povidone-iodine antiseptic solution alone (group A) and 197 cases in 2017-2019 with additional intrauterine douche using HClO (group B). HClO was used at a concentration of 200 ppm of residual chlorine. One gram of Ceftriaxone Sodium Hydrate was administered by drip infusion during MEA in both groups. Oral antibiotics were administered after MEA only in group A but not in group B. RESULTS: Mean patient age (mean ± SD; years old) was 44.5 ± 4.6 in group A and 44.8 ± 5.4 in group B, and mean operation time (min) was 30.4 ± 19.1 in group A and 34.4 ± 22.6 in group B, respectively. Neither were significantly different between groups. The combined ablation techniques i.e. transcervical microwave myolysis and transcervical microwave adenomyolysis did not increase frequency of infection. Postoperative intrauterine infection cases in group B (8 cases) were significantly lower than those in group A (28 cases) (Chi-square test, P = 0.001). Hysterectomy was performed in three severe intrauterine infection cases in group A, but no cases of severe intrauterine infection was found in group B. No adverse effect of HClO was seen. CONCLUSION: Intrauterine douche using HClO decreases postoperative intrauterine infection after MEA.

Submyometrial vasopressin injection before microwave ablation of vascular-rich submucosal myomas: a preliminary case study.

Purpose: Vascular-rich myomas are resistant to treatment involving transcervical microwave myolysis. To overcome cooling by blood perfusion, we injected dilute vasopressin solution into the space between the myometrium and the surface of the vascular-rich myomas. Material and Methods: Seven outpatients [age (mean ± SD age), 44.9 ± 3.9 years] with a single symptomatic vascular-rich submucosal myoma measuring 4.2-9.2 cm (6.5 ± 2.5 cm) underwent transcervical microwave myolysis and microwave endometrial ablation. Before microwave irradiation, dilute vasopressin solution was injected into the space between the myometrium and the surface of the vascular-rich myoma. We assessed the changes in the volumes of the vascular-rich myomas and blood hemoglobin levels before and 3 and 6 months after treatment. In addition, improvements in menorrhagia and satisfaction after the operation were assessed using visual analog scales. Results: Submyometrial injection of dilute vasopressin effectively reduced the abundant blood flow. The vascular-rich myomas were necrotized and shrank significantly by 69.0% at 3 months and 72.4% at 6 months after the operation (p < .05). Blood hemoglobin levels significantly increased at 3 months (p < .01). In addition, the visual analog scale results indicated that menorrhagia improved subjectively and the patients were satisfied with the results of the operation. Conclusions: Vasopressin injection before transcervical microwave myolysis leads to extended necrosis of vascular-rich submucosal myomas.

[Combination Treatments to the Huge Ovarian Cancer with Liver Metastases].

We report a CR case of huge ovarian cancer with peritoneal and liver metastases who was operated bilateral ovaries, uterus and peritoneal metastases at first, followed by systemic chemotherapy and performed 4 times of radiofrequency ablation (RFA)and 2 times of liver resection(LR). The case was a 50-year-old woman. She suffered with bowel enlargement from over 1 year ago. Preoperative MRI finding was huge ovarian serous cyst with partial solid tumor inside. The major axis was about 30 cm. CA125 and CA19-9 levels were elevated. Tumor reduction surgery was performed with bilateral salpingooophorectomy and hysterectomy with resecting peritoneal metastatic lesions. Postoperative systemic chemotherapy(carbo- platin 550mg/day 1 plus paclitaxel 130mg/day 1, 8, 15)(CBDCA plus PTX)were performed amount 6 courses. Unfortu- nately liver metastases at S3, S4, S6, S7 and S8/5 appeared about 7months after operation.We restarted the CBDCA plus PTX therapy from 15 months after operation when the tumor maker elevated. After 18 courses of CBDCA plus PTX therapy liver metastases remained only at S3. But gradually tumors grew up and size of tumors increased in spite of 3 more courses of CBDCA plus PTX therapy. So we challenged 2 times of RFA at S8/5 metastases that grew most rapidly and the values of increasing tumor makers stopped elevating. Then we performed LR at S3 and S4 metastases and the values of tumor makers returned to the normal level. But next S6 and S7 metastases appeared, we chose the RFA at first. At last recurrence of S7 was resected and all of liver metastases were treated. We checked no peritoneal metastases twice at the time of operation. The values of tumor makers became the normal level. Now she is alive well without metastases over 6 years after first operation. RFA and LR were effective at liver metastases from ovarian cancer that became resistant to systemic chemotherapy.

Outpatient transcervical microwave myolysis assisted by transabdominal ultrasonic guidance for menorrhagia caused by submucosal myomas.

PURPOSE: The aim of this paper was to evaluate the effectiveness in day clinics of microwave endometrial ablation (MEA) on transcervical microwave myolysis for patients with menorrhagia caused by submucosal myomas. MATERIALS AND METHODS: Thirty-five outpatients (average age 44.8 ± 5.2 years (mean ± SD), range 34-58) with a single submucosal myoma that was 4-7 cm (5.5 ± 2.1 cm) in size underwent MEA with transcervical microwave myolysis using a specifically developed transabdominal ultrasound probe attachment for transcervical puncture. Primary outcomes were the changes in the blood haemoglobin level and the volume of myoma before and after the treatment. Secondary outcomes were the improvement in menorrhagia and satisfaction after the operation, assessed by visual analogue scale (VAS). RESULTS: The mean operation time was 27.9 ± 13.6 min. The myomas had shrunk by 56.2% at 3 months and 73.8% at ≥6 months after the operation. Blood haemoglobin levels had increased significantly at 3 months (10.2 ± 2.0 vs. 12.7 ± 1.2, p < 0.001). The average VAS assessment of menstrual bleeding had decreased to 1.7 ± 1.7 at 3 months after the operation (preoperative VAS = 10). The average VAS score for feelings of satisfaction 3 months after the operation was 9.8 ± 0.5 (full score = 10). CONCLUSIONS: MEA with transcervical microwave myolysis is a feasible and effective procedure in a day surgery clinic for menorrhagia caused by submucosal myomas. The procedure may be an alternative to hysterectomy for menorrhagia caused by submucosal myomas in women during the perimenopausal period.

Guidelines for office gynecology in Japan: Japan Society of Obstetrics and Gynecology and Japan Association of Obstetricians and Gynecologists 2011 edition.

Gynecology in the office setting is developing worldwide. Clinical guidelines for office gynecology were first published by the Japan Society of Obstetrics and Gynecology and the Japan Association of Obstetricians and Gynecologists in 2011. These guidelines include a total of 72 clinical questions covering four areas (Infectious disease, Malignancies and benign tumors, Endocrinology and infertility, and Healthcare for women). These clinical questions were followed by several answers, backgrounds, explanations and references covering common problems and questions encountered in office gynecology. Each answer with a recommendation level of A, B or C has been prepared based principally on evidence or consensus among Japanese gynecologists.These guidelines would promote a better understanding of the current standard care practices for gynecologic outpatients in Japan.

Microwave endometrial ablation as an alternative to hysterectomy for the emergent control of uterine bleeding in patients who are poor surgical candidates.

BACKGROUND: Microwave endometrial ablation is a new, minimally invasive treatment option for menorrhagia. Its popularity in many countries is increasing due to its safety and simplicity. CASES: We treated menorrhagia due to submucosal myomas in two patients with a modified microwave endometrial ablation device. Surgery was contraindicated in the first patient secondary to medical co-morbidities and in the second patient because of acute hemorrhagic shock. In both cases, the operation was highly effective and each patient was satisfied with her treatment outcome. CONCLUSION: Given its safety, simplicity, and effectiveness, microwave endometrial ablation may be widely adopted for the emergent control of uterine bleeding in patients with poor surgical candidates.

Prevalence and Characteristic Features of Deep Venous Thrombosis in Patients with Severe Motor and Intellectual Disabilities.

Sudden death associated with patients with severe motor and intellectual disabilities (SMID) have been thought to be caused in part by venous thromboembolism (VTE), but actual situation of VTE in SMID is not clear. We examined the prevalence and location of deep venous thrombosis (DVT), and the relation of the development of crural veins in 16 patients with SMID, using ultrasonography. The maximum diameter of soleal vein was 1.6±0.5 mm. In most cases, DVT was found in the femoral veins. We could not detect thrombus in the soleal veins. In the present study, the detection ratio of DVT was high in patients with SMID who had restricted mobility capability and were bedridden, and we found the veins centrally from popliteal veins in DVT in SMID, not soleal veins, as the initial sites of the DVT. In the literature, the mean diameter of soleal veins, in healthy adults is 6.7±1.8 mm, that in contrast in SMID being smaller. Underdevelopment of intramuscular veins is possibly related to the mechanism of DVT in SMID. In the current guidelines for the management of VTE, there is limited in scope of ambulatory adults and no application cases who exhibit to SMID restricted mobility of the lower extremities and are bedridden associated with cerebral palsy and developmental motor disabilities, and such patients have associated high risk of the complications of DVT. According to our present study, it is necessary to provide appropriate guidelines for DVT in SMID considering characteristic features. (This is a translation of Jpn J Phlebol 2017; 28: 29-34.).

Resection of a cardiac tumor extending into the inferior vena cava presenting as Budd-Chiari syndrome.

This report describes the successful treatment of a case of cardiac adenocarcinoma with the clinical presentation as Budd-Chiari syndrome. Complete surgical excision of the atriocaval mass was successfully achieved under deep hypothermic circulatory arrest. Histopathological diagnosis of this tumor was tubular adenocarcinoma with positive immunostaining by carcinoembrionic antigen. Subsequent systemic search could not detect any evidence of extra-cardiac primary site and distant metastatic lesion. A 2-year follow-up without any adjuvant therapy revealed no sign of recurrence.

[A case of complex endometrial hyperplasia with atypia treated by microwave endometrial ablation].

Complex endometrial hyperplasia with atypia (CEHA) often precedes an endometrial carcinoma. A nulli-gradiva woman at high risk due to various complications underwent microwave endometrial ablation (MEA) at a frequency of 2.45 GHz for treatment of CEHA as an alternative to hysterectomy. The endometrium near the internal orifice was conserved to avoid hematometra. Endometrial biopsy specimen from the neighborhood of the internal orifice did not show any signs of endometrial hyperplasia postoperatively. Two years after the operation, endometrial biopsy revealed recurrence. The second MEA was performed. MRI one month after the second operation revealed that the uterine lining was completely replaced by avascular area without signs of regrowing endometrium or endocevix. Eighteen months have passed without recurrence.

[Pathogenesis, diagnosis, and treatment of postoperative deep vein thrombosis].

Most postoperative deep vein thrombosis (DVT) arises from the venous systems of the pelvis and lower extremities, especially the soleal veins. Embolization of venous thrombi is related to the size and location of thrombi and movement of the lower limbs and commonly occurs within 1 week from the onset of formation. There are three steps in the final diagnosis of DVT: probable diagnosis by anamnesis and physical examination; screening diagnosis using quantitative tests; and definitive diagnosis using imaging tests. To determine embolic sources, venous echography, which is noninvasive and convenient, is the first choice. Therapeutic methods are selected based on thrombi extent and time after formation. Anticoagulant therapy is indicated in all cases except in patients with possible bleeding tendency and continues for 3 months or more. Among the endovascular therapies, catheter-directed thrombolysis is a more effective approach when combined with a temporary vena cava filter than operative thrombectomy. Although the prevention of DVT is mandatory for surgeons, it is difficult to avoid venous thromboembolism completely. Systemic early diagnosis and emergent therapeutic strategies for venous thromboembolism are clinically effective and promising.

Deep Vein Thrombosis in Patients with Severe Motor and Intellectual Disabilities, Especially Diagnosis and Prevention of Recurrence for Chronic Thrombosis-Serial Changes of Sonography and D-Dimer.

Most patients with severe motor and intellectual disabilities (SMID) have restricted mobility capability and have been bedridden for long periods because of paralysis of the extremities caused by abnormal muscular tonicity due to cerebral palsy and developmental disabilities. Such patients are associated with a high risk of complications like deep vein thrombosis (DVT). Here, we report twelve patients (42.9%) with DVT among 28 patients with SMID during prolonged bed rest. However, we did not detect thrombosis in the soleal veins, finding it mostly in the femoral and common femoral veins. We applied anticoagulant therapy (warfarin), and carefully followed up the cases with DVT, regulating the warfarin dosage at prothrombin time-international normalized ratio (PT-INR) values around two to prevent recurrence of chronic thrombosis. Regarding laboratory data for the coagulation system, there were no cases above 5 µg/ml for the D-dimer and there were significant differences between the DVT and non-DVT groups in the D-dimer levels. The plasma levels of D-dimer in patients with DVT diminished to less than 1.0 µg/ml after warfarin treatment. Concerning sudden death (4.2%) in patients with SMID, we have to be very careful of the possibility of pulmonary thromboembolism due to DVT. Therefore, we should consider the particularity of the underdeveloped vascular system from underlying diseases for the evaluation of DVT. A detailed study of DVT as a vascular complication is very important for the smooth medical care of SMID, and serial assessment of compression Doppler ultrasonography of the lower extremities, as a noninvasive examination and measurement of D-dimer, is very helpful. (This article is a translation of Jpn J Phlebol 2014; 25: 34-42.).

Successful microwave endometrial ablation in a uterus enlarged by adenomyosis.

Adenomyosis can cause severe menorrhagia, which is a common indicator of the need for hysterectomy. None of the ablative techniques developed over the last two decades are of use in treating menorrhagia in a uterus enlarged by deep adenomyosis. Using a curved microwave applicator specifically developed for enlarged uterine cavities, microwave endometrial ablation at a frequency of 2.45 GHz was successfully applied in the treatment of menorrhagia in a patient with adenomyosis and an enlarged uterine cavity 12 cm in length. Two weeks after the operation, the patient experienced a menstrual period of ten days with no flooding. Menstrual duration gradually decreased to six days over the following six months. The quality of life score recovered to within the normal range six months after the operation. The post-operative sub-endometrial low signal intensity zone on the T2-weighted magnetic resonance images, which corresponds to the region of necrotic tissue, vanished 12 months after the operation. Although microwave endometrial ablation using the curved applicator could not treat bleeding from deep adenomyosis lesions, it improved menorrhagia in the uterus, which would conventionally require a hysterectomy.

Transcervical microwave myolysis for uterine myomas assisted by transvaginal ultrasonic guidance.

AIM: The effects of transcervical microwave myolysis at 2.45 GHz after microwave endometrial ablation for menorrhagia were examined in patients with myomas. METHODS: A transcervical microwave irradiation system assisted by transvaginal ultrasonic guidance was developed. Ten patients waiting for microwave endometrial ablation for menorrhagia caused by myomas entered the study after complete informed consent was obtained. Their outcomes were examined at least 6 months after transcervical microwave myolysis using the system. After completion of microwave endometrial ablation, interstitial microwave irradiation was performed using a guiding needle set in a puncture adaptor attached to a transvaginal ultrasonic probe and a microwave applicator of 1.6 mm in diameter. Shrinkage of the myoma was measured at 3 months and > or =6 months after the operation. RESULTS: In nine patients with typical myomas, the major part consisting of a submucous or an intramural node 4.0-7.5 cm in size was necrotized. The typical myomas had shrunk by 41-68% at 3 months and 37-69% at > or =6 months after the operation. In one patient with a 6.8-cm cellular leiomyoma, necrosis was limited to the neighborhood of the applicator tip. Shrinkage was 17% at both 3 and 6 months. This patient required a second microwave endometrial ablation at 6 months to treat recurrent menorrhagia. None of the patients underwent hysterectomy after the treatment. No remarkable complications were encountered. CONCLUSIONS: Typical myomas shrink after microwave myolysis following microwave endometrial ablation. Transcervical microwave myolysis seems to be applicable as a low-invasive treatment for a typical myoma.

Ratio of directly necrotized volume to total volume of a submucosal myoma predicts shrinkage after microwave endometrial ablation.

AIM: To explore parameters relating to shrinkage of submucosal myomas after microwave endometrial ablation. METHODS: Fourteen patients underwent microwave endometrial ablation at 2.45 GHz using a curved microwave applicator to treat menorrhagia caused by a submucosal myoma. The size of myomas was measured on magnetic resonance images before, one month after, and six months after the operation. The average radius r was defined as half of the size of the myoma measured in three dimensions. The protrusion ratio alpha was defined as the ratio of the thickness of the protruding part of a myoma in the uterine cavity to the size of the myoma before the operation. The ratio of the directly necrotized volume by microwave irradiation to the total volume (RODNeV) of preoperative myomas was calculated using the following formula: (1) where d is the depth of myoma tissue directly necrotized by microwave irradiation. The relationships of preoperative alpha, r and RODNeV to postoperative shrinkage were then examined. RESULTS: Two-dimensional plots showing shrinkage of submucosal myomas versus the RODNeV indicated that shrinkage at six months after microwave endometrial ablation depends on the RODNeV. Myomas with a RODNeV greater than 0.17 had shrunk more than 50% at six months after the operation. CONCLUSIONS: RODNeV is closely related to postoperative necrosis and shrinkage of the submucosal myoma after microwave endometrial ablation. Prediction of the shrinkage rate of submucous myomas appears to be possible by calculating the RODNeV preoperatively.

Saphenous vein graft aneurysm after coronary artery bypass grafting.

Saphenous vein graft (SVG) aneurysms are an unusual but potentially fatal complication after coronary artery bypass grafting (CABG). We report a case of multiple SVG aneurysms 23 years following CABG. Although the patient was on dialysis and had a poor left ventricular function, the aneurysms were successfully excised, and the ascending aorta was uneventfully replaced to be possible for percutaneous coronary intervention in the near future.

Pitfall of percutaneous cardiopulmonary support for acute massive pulmonary embolism.

The pitfall of percutaneous cardiopulmonary support (PCPS), which is thought to be useful for the detection of massive pulmonary emboli in patients, was investigated. A case of massive pulmonary embolism occurring 9 days after repair of the left Achilles tendon in a 31-year-old woman is described. Preoperatively, the thrombi in the right atrium and between the left popliteal vein and soleus muscle vein, as well as a massive pulmonary emboli, were detected. Despite using PCPS, it was difficult to maintain arterial pressure because of the outflow cannular occlusion caused by the floating thrombus in the right atrium, and so therefore the patient became hemodynamically unstable. After the removal of the thrombus and after a cardiopulmonary bypass was established, a pulmonary embolectomy was performed.

Microwave endometrial ablation for menorrhagia caused by large submucous myomas.

AIM: To examine the feasibility of microwave endometrial ablation (MEA), using a curved microwave applicator, in patients with menorrhagia caused by a submucous myoma greater than 3 cm in diameter, which is among the contraindications for conventional endometrial ablation. METHODS: Patients included were refractory to medication, more than 45 years of age, and due to undergo hysterectomy to treat menorrhagia as a result of submucous myomas, although they hoped to avoid hysterectomy. Three patients underwent MEA at 2.45 GHz using a curved microwave applicator and microwave tissue coagulator to treat menorrhagia. Patients 1, 2 and 3 had submucous myoma nodes 4.5, 5.0 and 13 cm in diameter respectively. The applicator was guided under transabdominal ultrasonography to microwave irradiation sites arranged to cover the entire uterine lining based on preoperative magnetic resonance images. MEA was performed under general anesthesia or spinal anesthesia. Microwaves were irradiated at 40 W for 50 s for single irradiation sites. RESULTS: Patient 1 became amenorrheic after the second MEA, which was performed 2 months after the first operation. Patients 2 and 3 became amenorrheic after the first MEA. Postoperative abdominal pain was controllable by a suppository of non-steroidal anti-inflammatory drugs. The patients were discharged the day after the operation. No remarkable complications were encountered during or after surgery. CONCLUSION: Microwave endometrial ablation improves menorrhagia caused by large submucous myomas when the microwave applicator reaches all parts of the uterine cavity.

Microwave power and duration without extrauterine thermal damage in microwave endomyometrial ablation at 2.45 GHz.

AIM: We investigated microwave power and duration of use, which does not affect extrauterine organs, in order to treat organic menorrhagia caused by myomas or adenomyosis. METHODS: Electric fields around a microwave applicator at a frequency of 2.45 GHz were calculated using the finite element method with commercially available software for analysis of electromagnetic fields. Transient temperature distributions around the applicator were obtained by numerically solving the bioheat transfer equation during microwave irradiation for 120 s in the human uterus and swine liver. We compared areas enclosed by the 60 degrees C isotherm obtained using numerical simulations and necrosis areas after microwave irradiation. Postoperative avascular areas in a Gd-enhanced MRI of a uterus enlarged by adenomyosis after clinical microwave endomyometrial ablation were compared with numerical simulations. RESULTS: There was good agreement between the calculated results and the experiments. At 40 W of output power for 50 s of duration and 64.5 W for 100 s, the depth of the necrotized uterine wall did not increase beyond 7 mm and 11 mm, respectively, either in the calculations or the experiments. Generally, the 50 degrees C isotherm was located approximately 2 mm external to the 60 degrees C isotherm in temperature distributions. The Gd-enhanced MRI after the operation depicted avascular areas, which agreed with the results of numerical simulations. CONCLUSIONS: The myometrial portion of a uterine wall > or = 13 mm throughout the uterus irradiated for < or = 64.5 W for 100 s is sufficient to avoid thermal damage of the extrauterine organs during microwave endomyometrial ablation.

Off-pump axillo-coronary artery bypass grafting with porcelain aorta.

Coronary artery bypass grafting (CABG) in patients with severely diseased ascending aorta has been associated with high risk for cerebral vascular accidents due to atheromatous embolism. In this situation, aortic no-touch techniques are widely employed as most important surgical strategy to prevent these complications. A case of 75-year-old man with effort angina associated with porcelain ascending aorta was reported here. He successfully underwent off-pump axillo-coronary bypass grafting with saphenous vein graft and has remained uneventful during his follow-up period. The off-pump axillo-coronary artery bypass grafting seemed to be an appropriate procedure for coronary revascularization with severely diseased ascending aorta.