Posthysterectomy fallopian tube herniation. A report of two cases

BACKGROUND: Tubal herniation as a complication of hysterectomy is a rare phenomenon, markedly more frequent after vaginal hysterectomy. With the increasing use of the vaginal route, the ratio between tubal herniation after vaginal versus abdominal hysterectomy may exceed 3:1. CASE: We report two cases of tubal herniation into the vagina, one after vaginal hysterectomy and the other after total abdominal hysterectomy, in two patients, aged 36 and 37 years. CONCLUSION: A tubal prolapse in the vagina may be considered a hernia and occurs only if a communication exists between the peritoneal cavity and vaginal canal. It can be an early or late prolapse. Symptoms consist almost exclusively of persistent blood loss and/or leukorrhea, dyspareunia and chronic pelvic pain. Whether the abdominal or vaginal approach should be used in surgical correction of prolapsed tubes must be decided in each case according to the patient's individual characteristics. Both histologic pictures described merit careful attention, distinguishing between the terminal tubal segment and the more cranial tract (above the vaginal strangulation).     

Surgical management of congenital high vaginal atresia

In the past 15 years five neonates and children have been treated for high vaginal atresia at the Surgical Unit of Department of Pediatrics, University Medical School, Pécs, Hungary. In three of the six patients distal atresia of the vagina was found (Type III). Two of the three were neonates and had a large hydrometrocolpos and the third, a 13-year-old girl, hematometrocolpos. In the fourth patient the vaginal atresia was associated with cloacal and anorectal malformation (Type V). In the fifth there was a duplication of uterus and vagina; however, only one of the two vaginas was atretic. In three patients a pull-through of the vagina was carried out, in one of them according to Pena, in another a transvesical approach, as suggested by Monfort, was used. Following repeated surgeries in the patient with cloacal malformation the vagina was replaced with large intestine. In the case of duplication of vagina and uterus one half of the duplication was removed.     

Treatment of women with the galactorrhea-amenorrhea syndrome with pyridoxine (vitamin B6)

Three women with the galactorrhea-amenorrhea syndrome and elevated prolactin concentrations experienced a return of regular ovulatory menses within 37-94 days after starting pyridoxine treatment (200-600 mg/day). In each the galactorrhea ceased and serum prolactin levels were maintained in the normal range while taking pyridoxine. In two other women with prolonged secondary amenorrhea but without hyperprolactinemia or galactorrhea, pyridoxine at dosages up to 600 mg/day did not restore ovulatory menses. Pyridoxine treatment was also ineffective in decreasing profuse galactorrhea in one woman with normal prolactin levels and regular ovulatory menses. In the three women effectively treated with pyridoxine, the galactorrhea returned, serum prolactin levels increased, and the menses ceased after discontinuing pyridoxine. These results imply that pyridoxine, by decreasing the excessive secretion of prolactin, may be useful in the long-term medical management of women with hyperprolactinemia and the galactorrhea-amenorrhea syndrome.     

High incidence of aneurysm formation following patch plasty repair of coarctation

Repair of aortic coarctation was performed in 152 adolescent and adult patients (mean age 28.5 years, range 14-67 years). Ninety patients were treated with patch plasty, 33 with end-to-end anastomosis, 18 with interposition of a tubular graft, 6 with prosthetic bypass and 5 with direct plasty. There were two (1.3%) early and ten (6.6%) late deaths after 2.9 to 11.8 (mean 6.6) years. Of the remaining 140 patients, 129 (92.1%) were reexamined with computed tomography and angiography after 1.5 to 17.2 (mean 9.1) years postoperatively. In 27 patients (35.1%) of the patch plasty group significant dilatation at the operative site was observed and reoperation for aneurysm formation was required in 15 patients (19.5%). Resection of the intimal crest did not increase the probability of aneurysm formation, whereas Dacron as patch material and late hypertension had a significant influence. Six of the ten late deaths occurred in the patch plasty group. Rupture of an aneurysm at the operative site was proved in two of these patients, and three patients died suddenly for unknown reasons. In the other groups significant dilatation was observed in 13 patients and 3 local aneurysms required reoperation (2 after end-to-end anastomosis and 1 after direct plasty). We conclude that patch plasty repair of coarctation should be abandoned in adults. End-to-end anastomosis is advisable only if possible without excessive tension. Reoperation with interposition of a tubular graft on left heart bypass proved to be a safe method.     

Oxyphilic cell variant of endometrioid adenocarcinoma

A case of oxyphilic cell variant of endometrioid adenocarcinoma is presented. To the best of our knowledge, there have been only three such cases reported in the English literature. The patient was a 35-year-old Japanese female (gravida 0, para 0). She was slightly obese with profuse vaginal bleeding. Histological examination of the resected uterus revealed endometrioid adenocarcinoma with an exclusive oxyphilic cell component. There was no evidence of myometrial invasion nor lymph node metastases. Reported cases of oxyphilic cell variant of endometrioid adenocarcinoma, including the present case, were stages 0-1 and grades 1-2. Although further study is necessary to evaluate this variant, oxyphilic cell variant seems to be an early stage of adenocarcinoma and should be differentiated from eosinophilic metaplasia and other types of adenocarcinoma of the endometrium.     

Pure pleomorphic rhabdomyosarcomas of the uterus

Pure rhabdomyosarcoma arising in the uterus is a rare tumor currently classified by the World Health Organization (WHO) as a uterine sarcoma. The records of eight women with uterine rhabdomyosarcomas were retrieved from the files of the Armed Forces Institute of Pathology (AFIP). The eight women presented with vaginal bleeding, abdominal enlargement, or acute abdomen. The mean age of the patients was 64.6 years (range 35-87). Macroscopically, 4 tumors were polypoid endometrial masses, 2 were intramyometrial, 1 was located in the cervix, and 1 was a 15-cm mass involving the endometrium and myometrium with direct extension into the small intestine. Microscopically, the tumors consisted of a variable proportion of large rhabdomyoblasts admixed with smaller round, polygonal, and spindle-shaped cells. No epithelial elements were identified on light microscopy. Tissue from the extrauterine and metastatic lesions was available for review in four cases and also showed pure rhabdomyosarcoma. Immunohistochemical assessment of seven tumors supported the sarcomatous nature of the neoplastic cells. Six patients died of disease within 15 months of initial diagnosis and 1 patient died of a pulmonary embolus. The patient whose 15-cm tumor had extended into the small intestine survived 6 years; she died of a presumed pancreatic carcinoma. Presenting mainly in elderly women, uterine pleomorphic rhabdomyosarcomas are rare, highly malignant tumors with frequent extrauterine spread at presentation. Patients rarely survive beyond 15 months.     

The effect of nephrectomy on the outcome of renal transplantation in patients with polycystic kidney disease

A new original method of interlamellar sectorial keratoplasty is proposed for surgical correction of astigmatism. Eleven operations were carried out in 8 patients (11 eyes) with astigmatism of 4 to 7.0 diopters. Vision acuity without correction was 0.6 to 1.0 in 5 patients (7 eyes, 63.6%). In 2 patients (2 eyes, 18.2%) vision acuity without correction was 0.3 to 0.5 diopters, and in 2 more patients (2 eyes, 18.2%) it was from 0.1 to 0.3 diopters, that is, equal to the maximal vision acuity with the optimal correction. The refraction effect stabilized in 3-4 months. The highest refraction effect attained was 7.0 diopters. The patients were followed up for 3 months to 4 years. Clinical analysis of the operations confirmed the efficacy and reliability of the method and stability of refraction. Interlamellar sectorial keratoplasty is recommended for surgical correction of astigmatism.     

The surgical procedure in the Mallory-Weiss syndrome

The authors dealt with treatment of 112 patients aged 27-70 years with the Mallory-Weiss syndrome. The diagnosis was confirmed by esophagogastroduodenoscopy. Diathermocoagulation was used in order to arrest bleeding. In profuse bleeding the margins of the mucosa fissures were first infiltrated with a solution of adrenaline. The Blakemore [correction of Bleikmorr] probe compression method was also used. Organ-saving operations were performed for continuing and recurrent bleedings. Two elderly patients with severe coexistent disease died. The authors consider that patients with the Mallory-Weiss syndrome must be treated by conservative methods. Operations for disruptions of the esophagus mucosa and acute blood loss will entail great risk.     

Laparoscopy-assisted and -prepared hysterectomy. A series of 80 cases

OBJECTIVE: Our objective was to determine the interest of laparoscopic assisted vaginal hysterectomy. STUDY DESIGN: Between January 1991 to december 1994, 80 patients had laparoscopically assisted vaginal hysterectomy. We reviewed with particular emphasis characteristic indications, complications. RESULTS: Eighty were performed as laparoscopically assisted vaginal hysterectomy. 14 patients (17.5%) had laparotomy conversion; because of size of uterus in 3 cases, suspected ovarian tumor in 3 cases. Pelvic adherences in 4 cases, urinary tract injuries in 1 case, hypercapnia in 1 case, hemorrhage in 2 cases. 9 patients experienced febrile morbidity and 1 urinary infection. 1 patient received 2 units of packed red blood cells. The hospital stay was 5 days for laparoscopically assisted vaginal hysterectomy versus 5.9 for laparotomic hysterectomy. CONCLUSION: Laparoscopically assisted vaginal hysterectomy offers a technique to convert certain abdominal hysterectomies into vaginal hysterectomies with a 17.5% laparoconversion rate.     

Novel approach to the treatment of intestinal fistula in the inaccessible abdomen: transbursal end-to-side duodenogastrostomy

BACKGROUND: Treatment of enterocutaneous fistula in patients with intra-abdominal sepsis and a surgically inaccessible abdomen is frequently unsuccessful. METHODS: A new approach has been devised: total disconnection of the proximal digestive tract, which can be performed through the bursa omentalis without entering the scarred abdomen. RESULTS: The procedure was carried out in four patients with high-output small bowel fistula and an inaccessible abdomen. Output of fistulas stopped promptly, recovery from intra-abdominal sepsis was achieved, the abdomens became accessible again and continuity of the digestive tract could be restored in all patients after intervals of 2-5.5 months. CONCLUSION: Transbursal end-to-side duodenogastrostomy is a useful procedure when traditional surgical interventions have failed or cannot be applied.     

The outcome of adjusted accumulation dose of treatment of Graves'' disease

Etiology of syringomyelia associated with Chiari type I malformation has been unknown. Moreover, the surgical procedure of foramen magnum decompression for this type of syringomyelia has not been standardized yet. No one procedure has been always successful, leading to many alternative procedures. The purpose of the present study is to elucidate pathway of cerebrospinal fluid into the syrinx cavity and to find out the best procedure for this disease. Fourty two patients with syringomyelia associated with Chiari type I malformation, which were diagnosed with magnetic resonance imaging (MRI), underwent surgical treatment. In all patients, craniocervical junction anomalies, cervical disc herniation and other spinal diseases were ruled out. There were 26 men and 16 women, ranging from 6 to 72 (mean: 42.3) years in age. The size, length and position of upper end of each syrinx cavity and the degree of the tonsillar herniation were measured on preoperative T1-weighted image and were compared each other. There were no significant relationship between the degree of tonsillar herniation and the size, length and position of syrinx cavity. No case showed that the upper end of syrinx cavity communicated to the 4th ventricle. The results suggest that the pathway of cerebrospinal fluid into the the syrinx cavity was not central canal from the 4th ventricle but microcanals in the spinal cord. All patients were carried out with foramen magnum decompression, which was divided into 4 groups according to the degree of decompression: 1) tonsillectomy group: 12 patients underwent subocciptital craniectomy (SOC) with patcy-graft dural plasty using lyophilized dura mater and tonsillectomy, 2) lysis group: 7 underwent SOC, dural plasty and microsurgical lysis of arachnoidal trabecula and fibrinoid filament around herniated tonsil, 3) plasty group: 17 underwent SOC and dural plasty and 4) dural group: 6 underwent SOC and removal of the outer layer of the dura mater. The mean follow-up periods were 3.7 years in tonsillectomy group, 3.6 years in lysis group, 2.3 years in plasty group, 1.8 years in dural group, respectively. Evaluation of the result following four types of surgical treatments was performed on clinical symptoms and the volume of syrinx cavity on sagittal MRI. The ratio in the area of the syrinx and spinal cord on preoperative and postoperative sagittal MRI were measured. There was no significant difference among 4 groups on the degree of reduction of syrinx in the sagittal plane as evaluated on MRI, whereas with regards to improvement of the clinical symptoms, dural group was significantly worse than the other three groups. The surgical procedure of dural plasty was clearly less invasive than those of tonsillectomy and lysis of subarachnoidal trabecula. These results suggest that we should select dural plasty as a primary surgical procedure for syringomyelia associated with Chiari type I malformation.     

High-dose-rate intracavitary brachytherapy in the management of cervical and vaginal intraepithelial neoplasia

PURPOSE: To assess the effectiveness of high-dose rate intracavitary brachytherapy (HDR-ICR) in patients with grade 3 cervical intraepithelial neoplasia (CIN-3) and grade 3 vaginal intraepithelial neoplasia (VAIN-3). METHODS AND MATERIALS: This was a retrospective analysis in 20 patients with CIN-3 (n = 14) or VAIN-3 (n = 6), average age 61.9 years, managed with HDR-ICR at Kanagawa Cancer Center. Two patients with CIN-3 with microinvasive foci and 11 other patients with CIN-3 were treated with HDR-ICR for cervical lesions. Six patients with CIN-3 after hysterectomy received HDR-ICR for recurrent or residual VAIN-3 lesions. One patient received radiation therapy for both CIN-3 and VAIN-3 lesions. All these patients but one were postmenopausal. RESULTS: Seventeen patients were treated with HDR-ICR alone, and three with combined external radiation therapy. The dose was calculated at Point A located 2 cm superior to the external os and 2 cm lateral to the axis of the intrauterine tube for intact uterus. For lesions of the vaginal stump, the dose was calculated at a point 1 cm superior to the vaginal apex or 1 cm beyond vaginal mucosa. In the 14 patients treated for CIN-3 lesions, the mean total dose of HDR-ICR was 26.1 Gy (range 20-30). Six patients received HDR-ICR for VAIN-3 lesions with mean dose of 23.3 Gy (range 15-30). At follow-up (mean 90.5 months; range 13-153), 14 patients were alive and 6 had died owing to nonmalignant intercurrent disease. No patient developed recurrent disease. Rectal bleeding occurred in three patients, but this symptom subsided spontaneously. Moderate and severe vaginal reactions were noted in two patients, in whom the treatment had included the entire vagina. CONCLUSIONS: HDR-ICR can be employed as the primary management strategy for postmenopausal women with CIN-3. In intraepithelial neoplasia involving the vaginal wall after hysterectomy, HDR-ICR should be considered as an alternative to total vaginectomy.     

Vaginal hysterectomy for the large uterus

OBJECTIVE: To assess the feasibility and safety of performing vaginal hysterectomy on enlarged uteri the equivalent of 14 to 20 weeks of gestation in size. DESIGN: A prospective observational study. SETTING: The Royal Free Hospital, London. PARTICIPANTS: Fourteen consecutive women undergoing vaginal hysterectomy for uterine fibroids up to 20 weeks in size. INTERVENTIONS: Vaginal hysterectomy with or without bilateral salpingo-oophorectomy or oophorectomy. MAIN OUTCOME MEASURES: Uterine size and weight, techniques used to reduce uterine size, surgical outcome, operative time, estimated operative blood loss, intra- and post-operative complications, duration of hospitalisation. RESULTS: The mean uterine size was 16.3 weeks (range 14 to 20 weeks). All hysterectomies were completed successfully by the vaginal route. The uteri weighed 380 to 1100 g, with a mean of 638.7 g. Bisection combined with myomectomy and morcellation were used in most cases to obtain reduction in uterine size, whereas coring was only utilised in two cases. The mean operating time was 84.3 min with a range of 30 to 150 min. The only complications were transient haematuria (n = 6) and superficial vaginal grazes (n = 5). One of the women required a blood transfusion. The mean post-operative hospital stay was 3.7 days (range 2 to 9 days). CONCLUSION: Enlargement of the uterus to a size equivalent to 20 weeks of gestation should no longer be considered a contraindication to vaginal hysterectomy. Many more hysterectomies should be carried out vaginally without resorting to abdominal or laparoscopic surgery.     

Case reports: unrecognized oviduct pregnancy and therapeutic abortion by uterine aspiration

2 cases of unrecognized oviduct pregnancy receiving therapeutic abortion by uterine aspiration are reported. A 29-year-old white female, gravida 4, para 2 with a Dalkon Shield in place for 2 1/2 years and with 6 weeks amenorrhea received a therapeutic abortion. 3 days later the patient complained of fever and severe suprapubic cramps. Minocycline was given in the belief that the patient was suffering from endometritis. 17 days after uterine aspiration the pain increased. At laparoscopy a corpus luteum was seen in the left ovary and blood was present in the pelvis. Histological examination of the oviducts revealed signs of an aborted oviduct pregnant. A 2nd case concerned a 26-year-old white female, gravida 2, para 2, using the Ogino-Knaus method of contraception and who had a normal menses 7 weeks previously. 12 days after uterine aspiration the patient complained of continued vaginal bleeding, lower abdominal cramps, and chills. After uterine aspiration was repeated minocycline therapy was initated. 20 days after the initial aspiration the patient reported a return of vaginal bleeding and lower abdominal pain. Laparotomy revealed a ruptured oviduct. Histology showed salpingitis and fusion of the right fimbria and a large blood clot and trophoblastic villi in the lumen of the right ampulla. In the future it is suggested that histological examination of the aspiration should be performed to aid in finding oviductal or ovarian pregnancies.     

Isotypic antibody responses of a population in an endemic area of schistosomiasis japonica and their epidemiologic significance

OBJECTIVE: Chordal transposition was advocated for correction of anterior mitral prolapse. We have evaluated the early and late results of this technique in different anatomical presentations. METHODS: From 1986 to 1995, 185 mitral valve repairs were carried out for pure mitral regurgitation due to a degenerative disease. Eighty-nine patients had either an anterior prolapse (39) or prolapse of both leaflets (50) at initial presentation and underwent chordal transposition from the mural leaflet to the anterior leaflet. The corrective procedure was completed by polytetrafluoroethylene or pericardial posterior annuloplasty. Twenty patients presented a complex pathology and 26 had chordal elongation of mural leaflet. Annular calcifications were found in 9 patients. Seven patients required shortening of transposed chordae and two patients the additional shortening of an anterior chorda. RESULTS: Operative mortality was 3.3% and follow-up was 95% complete (average 41 months). There were five postreconstruction valve replacements (two earlier and three later) for a probability of freedom from late reoperation or 3+ mitral regurgitation of 88.6 +/- 4.8% at 5 years. Of the patients 79% presented no or trivial residual MR, 17% moderate MR and 4% severe MR. The presence of a complex pathology or posterior chordal elongation did not influence the entity of postoperative residual regurgitation. On the contrary, the patients with annular calcifications had a residual regurgitation/left atrium area ratio greater than patients without annular calcification (15.8 +/- 11.5% vs. 6.1 + 9.9%; P = 0.009). CONCLUSIONS: Chordal transposition is an effective and easily carried out technique for the correction of anterior mitral prolapse. The presence of a complex pathology or posterior chordal elongation do not rule out the procedure. The absence of annular calcification is important in order to obtain a satisfactory correction.     

Loop excision of the transformation zone (LETZ) as an outpatient method of management for women with cervical intraepithelial neoplasia: our experience

Between March 1996 and July 1998, 90 patients were treated with diathermy loop excision (LETZ) for cytologically, colposcopically and histologically verified cervical intraepithelial neoplasias (CIN), at the outpatient clinic. In average, the patients were 30.22 years of age, and 61.1% of them were nulliparas. In 80 surgical samples (88.9%), the exocervical and endocervical margins were histologically free of disease. From the total of 65 patients with CIN III diagnosis, 58 (89.2%) had free margins samples. In the post-operative period the patients had a changed vaginal discharge for 16 days. A slight feeling of pain in the abdomen lasted for 2.5 days on the average, and most patients did not take analgetics. Moderate postoperative hemorrhage from the excision site occurred in 5 (5.5%) patients, and was outpatiently treated with electrocoagulation, with no need for blood replacement. In 65 patients (90.3%), the cytological control results were normal. During the follow-up period, 9 patients became pregnant, which resulted in 6 terminal deliveries so far; 2 pregnant women are about to deliver, and one is in the first trimester of pregnancy. Cerclage cervicis has not been performed on any of the patients. LETZ is a safe and simple procedure which can be done at outpatient clinics, it is relatively easily mastered, it is short, quite bearable for patients if done only under local analgesia, the equipment costs are acceptable, and the treatment can be used both diagnostically and therapeutically, since an adequate surgical sample is obtained for histological assessment. Cytological and colposcopical check ups are imperative in the postoperative period.     

Genital fistulas caused by diverticular disease of the sigmoid colon

OBJECTIVE: Our purpose was to bring to the attention of gynecologists a subject not mentioned in a single textbook of gynecology, namely, genital fistulas resulting from diverticular disease of the sigmoid colon. STUDY DESIGN: We report our experience with 13 genital fistulas caused by sigmoid diverticulitis. RESULTS: Ten fistulas involved the vagina, one the vagina and bladder, one the tube, and one the uterus. Average age of the patients was 68.6 years (range 54 to 89 years). Presenting symptom in 12 patients was a malodorous vaginal discharge. All with vaginal lesions had previously undergone total hysterectomy. A barium enema failed to demonstrate a fistula in 8 of 11 patients. Colonoscopy failed in 8 of 8 patients. All fistulas were demonstrated by retrograde dye studies. Ten patients operated on were cured. Three patients refused surgery; of these, 1 had intestinal obstruction, 1 may have had spontaneous closure of the fistula, and 1 is being observed. Surgery involved staged procedures in 2 patients, fistulectomy in 4, and bowel resection and anastomosis in 4. CONCLUSIONS: Sigmoidovaginal fistulas are the most prevalent variety of cologenital fistula caused by sigmoid diverticulitis. The diagnosis should be considered in a patient > 50 years old who complains of a foul vaginal discharge and has a history of total hysterectomy. Its presence is best demonstrated by vaginogram. Surgical therapy is advised, the extent of which will rest on the surgeon's judgment of the severity of the inflammatory process found at exploration.     

Biliary ileus

In the period 1946-1987 at the former Second Surgical Clinic of the Medical Faculty in Belgrade 25 patients with a biliary ileus were Surgically treated, 20 females (80%), and 5 males (20%), aged from 53 to 87 years, (mean 67 years). Six patients were decade, 7 in 7th, 9 in 8th, and 3 in 9th decade. In only 8 patients biliary calculosis had been confirmed earlier. Preoperative troubles in the Bowel Passage lasted 1-7 days, (mean 3 days), mostly as in incomplete gut occlusion. Preoperative diagnosis of the biliary ileus, using x-ray, was exact only in 3 cases (12%), while other remaining patients underwent Surgery diagnosed as ileus of the small bowel or acute abdomen. In 7 patients a stone obstructed the jejunum, in 6 ones its widpart and in 10 cases the terminal ileum. In 23 patients an enterotomy distally to the obstruction with an expulsion-extraction was done, in one patient a partial resection of the gut and in another patient a manual stone expulsion into the colon, with no enterotomy, was carried out, and after operation the stone was removed from the rectum. The Bilio-digestive fistula was never treated either the surgery itself, or later. Complications arised in 13 patients: wound infection in 11, deep thrombophlebitis in one and a pneumonia in two patients. An average hospitalization was 27 days, and all patients Survived.     

Use of calcitonin in treatment of bone pain

The studies were carried out assessing the effect of calcitonin in the treatment of bone pain. In the years 1990-1992 43 patients were studied. Pain intensity scale was used with evaluation by doctor and patient.