Laparoscopic appendectomy in modern gynecology.

Gynecologists frequently manage women with acute or chronic pain in the right iliac fossa. Appendicitis is one of the common conditions encountered in this setting. From the gynecologic perspective, issues regarding the role of laparoscopic appendectomy include radioimaging and laparoscopic diagnosis, operative technique, advantages and disadvantages, and laparoscopic appendectomy in pregnancy and in complicated appendicitis. Most studies are in favor of the procedure, and it seems reasonable to include it in training programs in gynecology.

Reducing costs of laparoscopic hysterectomy.

STUDY OBJECTIVE: To establish the role of laparoscopic hysterectomy using reuseable surgical equipment. DESIGN: Prospective, observational study (Canadian Task Force classification II-2). SETTING: Tertiary major teaching hospital. PATIENTS: Fifty consecutive women carefully selected for laparoscopic hysterectomy. INTERVENTIONS: The ultrasonically activated (harmonic) scalpel was used for coagulative cutting of pedicles and ligaments attached to the uterus and adnexa, backed by bipolar diathermy. No nonabsorbable material was left in the pelvis at the conclusion of the procedures. MEASUREMENTS AND MAIN RESULTS: Patient characteristics, uterine weight, histology, operating time, recovery, analgesic requirements, and hospital stay were recorded. Complications were noted and critically assessed for constructive quality assurance appraisal. Outcomes were satisfactory according to both patients and gynecologists. CONCLUSION: This pilot study suggests that the method is an efficacious, cost-effective, and well-controlled technique of laparoscopic hysterectomy.

The effects of danazol after endometrial resection--results of a randomized, placebo-controlled, double-blind study.

We report the results of a controlled, randomized, prospective, 'double blind' evaluation of the effect of danazol treatment in 120 patients after hysteroscopic endometrial resection. After endometrial resection, the women were allocated to 1 of 3 groups: Group A- placebo; Group B - high-dose danazol (600 mg daily); Group C - low-dose danazol (200 mg daily) plus placebo tablets. Tablets were specifically manufactured for the study, were identical in appearance, and were supplied in individual prepackaged boxes. The duration of treatment was 3 months and patients' compliance was noted. Amenorrhoea, dysmenorrhoea and premenstrual tension symptoms were assessed for each group by 1 or 2 independent gynaecologists at follow-up intervals of 6 weeks, 3, 6 and 12 months. A statistically-significant increased rate of amenorrhoea was found in patients who received treatment with the higher-dose danazol (600 mg day) following endometrial resection. While not statistically significant, the same trend was noted with the low-dose danazol. This result should influence our clinical management of women with menorrhagia, and the long-term results on the same cohort of patients are awaited with interest.

Tuberculosis meningitis, Abbassia Fever Hospital-Naval Medical Research Unit No. 3-Cairo, Egypt, from 1976 to 1996.

A total of 1,430 patients with the presumptive diagnosis of tuberculous meningitis were admitted to the U.S. Naval Medical Research Unit No. 3/Abbassia Fever Hospital in Cairo, Egypt from January 1976 to January 1996. Diagnosis was confirmed by culture of the mycobacteria from the cerebrospinal fluid CSF of 857 patients and these patients are included in the final analysis. There were 497 males and 360 females. The patients ranged in age from five months to 55 years. The number of patients admitted during the months of March, April, and May were more than double those admitted during October, November, and December. The duration of symptoms prior to admission ranged from seven to 90 days (mean = 29.5 days). Upon admission, 4% of the patients were alert, 34% were drowsy, and 62% were in a coma. Of the 857 patients studied, 490 (57%) died, 256 (30%) recovered completely, and 11 (13%) recovered with sequelae. The mortality and neurologic sequelae were directly related to the stage of disease and duration of symptoms prior to admission. Mortality was significantly lower in patients admitted in stage II and or with short duration of disease compared with those in stage III and or with prolonged duration of symptoms prior to admission. The use of dexamethasone in patients with tuberculous meningitis significantly reduced the ocular complications that occur in these patients and also significantly reduced the fatality rate.

Transcervical endometrial resection.

STUDY OBJECTIVES: To determine the safety and efficacy of endometrial resection, and to provide an indicator of the operative problems and treatment outcomes. DESIGN: Prospective study. SETTING: Academic practice tertiary care setting. PATIENTS: One hundred twenty-six consecutive women undergoing endometrial resection because of menorrhagia, who wished to retain their uterus. INTERVENTION: Hysteroscopic endometrial resection performed as a day procedure. MEASUREMENTS AND MAIN RESULTS: In 126 women, 2 cases of uterine perforation were readily identified on the operating monitor screen; they had no serious sequelae. Three patients had heavy uterine bleeding, which was controlled by intrauterine tamponade. No women had other serious complications. CONCLUSION: Hysteroscopic endometrial resection is a safe, successful, and cost-effective treatment of menorrhagia.

Female circumcision.

Three cases of female circumcision are presented together with a literature review. Unfortunately, this procedure frequently results in genital mutilation. Treatment with deinfibulation enables restoration of the external genitalia and vagina. Obstetric and gynaecological complications have been documented, but emotional and psychological effects may be difficult to assess. These women should be treated without bias and with sensitivity.

A new laparoscopic aspiration technique for ovarian dermoid cysts.

A new method for aspirating benign dermoid cysts enables removal of the collapsed cyst wall without the need for extending laparoscopic incisions or opening the pouch of Douglas. The technique has been used by one of the authors in 10 patients with good effect and minimal or no spillage of dermoid cyst contents into the peritoneal cavity.

Unusual contents of a dermoid cyst of the ovary removed by laparoscopy.

Benign cystic teratoma (dermoid cyst) of the ovary is a common pathological entity. Usually, the cyst contains representative tissues of the 3 embryonic germ cell layers: ectoderm, mesoderm and endoderm. Sebaceous material, hairs, cartilages, teeth, even thyroid tissue are frequently observed. In this case, the tumour was a well-formed jaw and tongue, and was successfully removed via the laparoscope.

Postpartum haemorrhoids--evaluation of a cooling device (Anurex) for relief of symptoms.

Postpartum haemorrhoids are a common problem, for which the recently marketed cooling device, Anurex (Roussel Uclaf Australia, Pennant Hills, NSW), was evaluated in 129 women randomly allocated to treatment and control groups. There was no difference in the rate of resolution of pain between the groups. The test group estimated a greater duration of pain relief, but this was not statistically significant. Anal bleeding and itching were not significantly reduced in the test group. There was no difference between discomfort scores related to application of the device in the groups, but a significant number in the test group encountered difficulty in insertion of the device. It is concluded that the introduction of the Anurex device as a standard method of treatment of postpartum haemorrhoids is not justified.

An unusual presentation of bilateral tubal ectopic pregnancy.

The diagnosis of ectopic pregnancy is sometimes difficult on clinical grounds because of the varied presentation. The clinical triad of amenorrhoea, abnormal vaginal bleeding and lower abdominal pain often raises the suspicion of the diagnosis. There are, however, instances where one or other feature of the triad may be absent.

Meningitis and encephalitis at the Abbassia Fever Hospital, Cairo, Egypt, from 1966 to 1989.

A total of 7,809 patients with meningitis or encephalitis were admitted to the Abbassia Fever Hospital in Cairo, Egypt from November 1, 1966 to April 30, 1989. The etiology was Neisseria meningitidis (mostly group A) in 27.3% of the patients, Mycobacterium tuberculosis in 19.7%, Streptococcus pneumoniae in 7.3%, and Haemophilus influenzae in 4.1%. Almost 27% of the cases had purulent meningitis but without detectable etiology; however, the epidemiologic data suggest that most of these had meningococcal meningitis. Encephalitis was suspected in 12.5% of the patients. Most of the meningococcal, pneumococcal, and Haemophilus cases occurred during the winter months. The number of meningococcal and culture-negative purulent cases per year reached a maximum three times during the 22.5 years of this study. There were more males than females in all etiologic groups, with the ratio for the total patient population being 1.6:1. The average age ranged between 11.7 and 16.5 years for all groups except for Haemophilus patients, who had a mean age of 2.5 years. The mortality rate was almost 55% for tuberculous patients and was approximately 40% for both pneumococcal and Haemophilus patients; it was 8.5% in patients with meningococcal disease.

Feto-pelvic disproportion of mimicking placental abruption.

An unbooked patient presented with severe eclampsia and sudden onset of abdominal pain, uterine tenderness and fresh vaginal bleeding. Unsuspected macrosomia and multiple congenital fetal malformation were discovered at delivery and a neonate weighing 7.545 kg was delivered. The infant died shortly afterwards.

The role of obstetric factors in perinatal mortality trends.

In the Perinatal Unit of the New Jersey Medical School, Newark the combined neonatal mortality and stillbirth rates declined from more than 51 per 1000 to less than 17 per 1000 between 1971 and 1983. This change is comparable to the reduction of perinatal mortality rates nationwide since the Second World War. Because the improvement in the fetal and neonatal survival rates occurred in a static population and against well identifiable changes in the structure, equipment, policies and management patterns of the obstetric unit, it was possible to assess the impact of various factors upon perinatal outcome. In the environment of this institution adherence to conservative concepts of obstetric management, avoidance of manipulative and extraction procedures, an increase of the rate of cesarean sections from about 7 to 15% and emphasis upon infection control appeared to be the crucially important factors. Antepartum sonography and fetal stress and non-stress testing significantly impacted upon the results. The role of intrapartum electronic monitoring was less clearly definable and seemed to be effective only in the hands of experienced physicians. The results did not seem to be adversely affected by the fact that the program de-emphasized invasive procedures, including fetal scalp pH sampling.

A comparative evaluation of the treatment of typhoid fevers with co-trimoxazole and chloramphenicol in Egypt.

Seventy-two patients with bacteriologically proven enteric fever were treated with either co-trimoxazole (41 cases) or chloramphenicol (31 cases). C0-trimoxazole was found to be superior to chloramphenicol in relieving the toxaemia. The average number of days required for patients to become afebrile was 5-5 days in the co-trimoxazole group and 4-5 days in the chloramphenicol group. The cure rate was 97 per cent in each of the treatment groups. There occurred two relapses in the co-trimoxazole group and four relapses in the chloramphenicol group. No side effects of the co-trimoxazole were detected during the study. Co-trimoxazole can be considered as a good alternative to chloramphenicol in the treatment of the enteric fevers.

Trimethoprim-sulphamethoxazole in acute brucellosis.

Eight patients with proved brucella infection were treated with trimethoprim-sulphamethoxazole. The dose varied from two to four tablets given twice daily for three weeks. Clinical response was rapid and all patients were asymptomatic and afebrile within two to seven days of starting therapy. Three patients relapsed clinically and bacteriologically within three weeks of ending treatment. There were no side effects of the treatment. It is suggested that the treatment be continued for at least six weeks to prevent relapses.