Early Discharge after Laparoscopic Hysterectomy: a Prospective Study.

OBJECTIVE: To evaluate the feasibility of same-day discharge after laparoscopic hysterectomy without excluding patients with complex surgical pathology and medical comorbidities. These factors are often considered potential barriers to early discharge, and the literature is lacking prospective trials addressing the feasibility of same-day discharge after laparoscopic hysterectomy in this patient population. METHODS: All women undergoing laparoscopic hysterectomy by a member of the minimally invasive gynaecology team at The Ottawa Hospital, a tertiary academic referral centre, from May 2013 to February 2015 were eligible to participate regardless of patient comorbidities or surgical complexity. Strict perioperative protocols are presented. Factors associated with decreased success of same-day discharge and baseline and postoperative quality of life surveys were analyzed. RESULTS: Fifty-three patients were included. Overall success of same day discharge was 83.0%. Average age and BMI were 44.4 years and 29.8 kg/m2, respectively. Thirty-four patients (63.0%) had at least one prior abdominal surgery. Those who had their surgery as first case of the day had a 91.7% same-day discharge rate versus 64.7% if they did not (relative risk = 1.4 [range 1.0-2.0]; P = 0.02). Ninety-eight percent of participants would recommend same-day discharge. Clinically significant improvement in quality of life from baseline was observed in 5 of 8 of the Short Form 36 domains at 6 months. CONCLUSION: Same-day discharge from hospital is reasonable and well accepted for patients undergoing laparoscopic hysterectomy, even with complex surgical pathology. The implementation of a successful same-day discharge program would mean greater efficiency, economic benefits, and improved access to surgical care for women.

Effect of Surgical Trainee Presence on Vaginal Hysterectomy Outcomes.

STUDY OBJECTIVE: Because of the rapid decline in vaginal hysterectomy (VH) cases in recent years, there is concern regarding gynecologic surgical training and proficiency for VH. The objective of this study is to determine the effect of surgical trainee involvement on surgical outcomes in VH cases performed for benign indications. DESIGN: Retrospective, multicenter, cohort study (Canadian Task Force classification II-2). SETTING: Participating hospitals in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) at various international sites. PATIENTS: Women who underwent VH for benign indication enrolled from the ACS-NSQIP from 2006 to 2012. INTERVENTION: ACS-NSQIP database. MEASUREMENTS AND MAIN RESULTS: Our study included 5756 patients who underwent VH, and surgical trainees were present in 2276 cases (39.5%). Patients who had a trainee present during VH were more likely to be older, nonsmoking, have comorbidities, and be classified as American Society of Anesthesiologists class III or IV. They were also more likely to be admitted as inpatients, undergo concomitant adnexal surgery, and have uterine weight greater than 250 g. Trainee presence during VH was associated with increased rates of overall complications (5.1% vs 3.19%, p < .001), urinary tract infection (5.27% vs 2.64%, p < .001), and operative time (124.25 ± 59.29 minutes vs 88.64 ± 50.9 minutes, p < .001). After controlling for baseline characteristics, trainee presence was associated with increased odds of overall complications (adjusted odds ratio, 1.63; 95% confidence interval, 1.25-2.13), urinary tract infection (adjusted odds ratio, 2.02; 95% confidence interval, 1.51-2.69), and prolonged operative time (adjusted odds ratio, 3.65; 95% confidence interval, 3.20-4.15). No differences were observed for other measures of surgical morbidity or mortality. CONCLUSION: Despite the increased patient complexity and operative time associated with teaching cases, the involvement of surgical trainees is associated with urinary tract infection but not with any major surgical morbidity or mortality. These findings have important implications for gynecologic surgical training for VH.

Treatment of Asherman's syndrome in an outpatient hysteroscopy setting.

OBJECTIVE: To evaluate the feasibility and success rate of treating Asherman syndrome in an outpatient hysteroscopy unit. DESIGN: Retrospective case series (Canadian Task Force classification III). SETTING: The outpatient hysteroscopy clinic at Ottawa Hospital from November 26, 2008, to January 31, 2014. PATIENTS: Patients undergoing treatment for Asherman syndrome. INTERVENTIONS: All cases of hysteroscopic adhesiolysis were reviewed. MEASUREMENTS AND MAIN RESULTS: Demographic data were collected by a retrospective chart review including patients' age, obstetric history, referring complaint, etiology of Asherman syndrome, antecedent treatment, and outcome measures when available. The severity of Asherman syndrome was determined based on the March classification by the operating surgeon. Analgesia used during the procedure was recorded. Twenty patients were treated for Asherman syndrome in the outpatient hysteroscopy suite. There were a total of 38 procedures (adhesiolysis or diagnostic hysteroscopies) performed for this indication in the patient set. The most common etiologies for intrauterine adhesions were previous curettage (60%) and previous missed abortion (45%). Outcomes were available for 19 patients. All of the patients had normal menses after treatment. Eighty-four percent of patients had either no adhesions or mild adhesions at their final hysteroscopy. Six patients had a spontaneous pregnancy after treatment, and 5 went on to have a term delivery to date. In terms of analgesia used for the procedure, 89% of patients had preoperative nonsteroidal anti-inflammatory drugs, 2.8% required intravenous fentanyl and midazolam, and 5.6% required oral lorazepam. CONCLUSION: This series showed that Asherman syndrome may be successfully treated in an outpatient hysteroscopy setting outside the operating room and without general or regional anesthesia.

A case of adolescent pelvic inflammatory disease caused by a rare bacterium: Fusobacterium nucleatum.

BACKGROUND: Pelvic inflammatory disease (PID) is a polymicrobial infection that typically occurs in sexually active females. PID is rare in premenarchal and/or noncoital young women; however, there are case reports of PID occurring in virginal females. We present the first reported case of PID associated with F. nucleatum. In this unusual case of PID in an adolescent, the responsible organism may have originated from the patient's oral cavity. CASE: A 13-year-old noncoital Caucasian female presented to a tertiary children's hospital with fever and acute abdominal/pelvic pain. She had experienced a perforated appendix 14 months prior, which was treated by laparoscopy. Postoperatively, she experienced intermittent episodes of recurrent abdominal pain. During this presentation, the physical examination and ultrasound findings were suspicious for an ovarian torsion. She was taken to the operating room where she had an examination under anesthesia and a diagnostic laparoscopy. Findings at the time of laparoscopy were in keeping with a diagnosis of pelvic inflammatory disease. Oral and pelvic fluid cultures were positive for F. nucleatum. She was subsequently treated with antibiotics and her symptoms resolved. SUMMARY AND CONCLUSION: This case highlights the importance of including PID in the differential diagnosis of noncoital adolescent females presenting with an acute abdomen. Although most Fusobacteria infections are periodontal in nature, translocated infections to the pelvis may have long-term implications for reproductive health. This case also highlights the importance of the role of diagnostic laparoscopy in young women who have persistent pain following previous surgery due to the potential of missed pathology or subclinical infection.

Delayed laparoscopic management of placenta increta.

BACKGROUND: Traditional methods of management of abnormal placentation are often associated with significant maternal morbidity. In an attempt to decrease such morbidity, we present a novel approach: delayed laparoscopic management. CASE: A patient with placenta increta was delivered by Caesarean section, followed by closure of the uterine incision, with the placenta left in situ. The patient underwent total laparoscopic hysterectomy three weeks later. She did not receive any blood product transfusions, either at the time of Caesarean section or at the time of hysterectomy. CONCLUSION: A laparoscopic approach may be considered for delayed surgical management of abnormal placentation. Key factors for success consist of a multi-disciplinary approach, the availability of skilled laparoscopic surgeons and advanced endoscopic equipment, and the availability of resources in the event of complications.

Laparoscopic internal iliac artery ligation for postpartum spontaneous hemoperitoneum.

BACKGROUND: Spontaneous hemoperitoneum in pregnancy or the postpartum period is an uncommon but potentially life-threatening complication. CASE: A 29-year-old woman presented with severe abdominal pain, decreased consciousness, and a reduced hemoglobin level three days after an uneventful spontaneous vaginal delivery. Initial ultrasound and CT imaging showed significant hemoperitoneum with no identifiable cause. Laparoscopic surgery was performed, during which bleeding from the left uterine artery was identified and resolved with laparoscopic internal iliac artery ligation. Concomitant cul-de-sac obliteration and adhesions secondary to decidualized endometriosis were found. CONCLUSION: Decidualized endometriosis is a possible etiologic factor in spontaneous hemoperitoneum. Prompt diagnosis and treatment are critical for improving outcomes. When surgical intervention is indicated, a laparoscopic approach should be considered because of its minimally invasive nature and shorter recovery time.

Unconventional neuroprotection against Ca2+ -dependent insults by metalloporphyrin catalytic antioxidants.

We evaluated whether both inert and catalytically active metalloporphyrin antioxidants, meso-substituted with either phenyl-based or N-alkylpyridinium-based groups, suppress Ca(2+)-dependent neurotoxicity in cell culture models of relevance to cerebral ischemia. Representatives from both metalloporphyrin classes, regardless of antioxidant strength, protected cultured cortical neurons or PC-12 cultures against the Ca(2+) ionophores ionomycin or A23187, by suppressing neurotoxic Ca(2+) influx. Some metalloporphyrins suppressed excitotoxic Ca(2+) influx indirectly induced by the Ca(2+) ionophores in cortical neurons. Metalloporphyrins did not quench intracellular fluorescence, suggesting localization to the plasma membrane interface and/or interference with Ca(2+) ionophores. Metalloporphyrins suppressed ionomycin-induced Mn(2+) influx, but did not protect cortical neurons against pyrithione, a Zn(2+) ionophore. In other Ca(2+)-dependent paradigms, Ca(2+) influx via plasma membrane depolarization, but not through reversal of plasmalemmal Na(+)/Ca(2+) exchangers, was modestly suppressed by Mn(III)meso-tetrakis(4-benzoic acid)porphyrin (Mn(III)TBAP) or by an inert analog, Zn(II)TBAP. Mn(III)TBAP and Zn(II)TBAP potently protected cortical neurons against long-duration oxygen-glucose deprivation (OGD), performed in the presence of antagonists of NMDA, alpha-amino-3-hydroxy-5-methylisoxazole-4-propionate and L-type voltage-gated Ca(2+) channels, raising the possibility of an unconventional mode of blockade of transient receptor protein melastatin 7 channels by a metalloTBAP family of metalloporphyrins. The present study extends the range of Ca(2+)-dependent insults for which metalloporphyrins demonstrate unconventional neuroprotection. MetalloTBAPs appear capable of targeting an OGD temporal continuum.

Confirmation of Essure microinsert tubal coil placement with conventional and volume-contrast imaging three-dimensional ultrasound.

OBJECTIVE: To determine the accuracy of ultrasound in the assessment of proximal fallopian tube positioning of the Essure microinsert coil 3 months after postprocedure. DESIGN: Prospective cohort study (Canadian Task Force classification II-2). SETTING: Reproductive-age women in a tertiary care hospital. PATIENT(S): Reproductive-age women presenting with a request for permanent contraception. INTERVENTION(S): Hysteroscopic sterilization with the Essure microinsert coil and conventional or volume-contrast three-dimensional (3D) ultrasound imaging 3 months after the procedure. MAIN OUTCOME MEASURE(S): Coil position on ultrasound. RESULT(S): Forty-eight of the 50 patients had successful placement of the Essure coils, and three patients required a second attempt on one tube. Conventional or volume-contrast (3D) ultrasound showed proper positioning of the coils within the proximal fallopian tube in 42 women (84%); five women (10%) required hysterosalpingogram to show appropriate positioning. Two patients (4%) required laparoscopic tubal sterilization, and one patient (2%) was lost to follow-up. CONCLUSION(S): Transvaginal ultrasound is an acceptable method of confirming proper placement of the Essure microinsert coil within the proximal fallopian tube 3 months after the procedure.

The gas7 protein potentiates NGF-mediated differentiation of PC12 cells.

The growth-arrest-specific protein gas7 is required for morphological differentiation of cultured mouse cerebellar neurons and PC12 cells. Moreover, its overexpression in various cell types induces neurite-like outgrowth. The role of gas7 in neuronal differentiation was further characterized by adenovirus-mediated overexpression in PC12 cells and quantification of the expression of various neuronal markers, in the absence and presence of different concentrations of nerve growth factor (NGF). The potential neuroprotective activity of gas7 against various neurotoxic insults was also assessed. In addition to promoting the formation of neurite-like extensions, overexpression of gas7 potentiated NGF-mediated neuronal differentiation of PC12 cells, as shown by the enhanced expression of the neuronal proteins betaIII-tubulin, synaptotagmin, alpha7 subunit of the acetylcholine receptor, and dihydropyrimidinase related protein-3. This effect was exerted independently of cell cycle progression, as gas7 did not affect proliferation of PC12 cells. While some differentiation enhancers protect PC12 cells against lethal insults, gas7 overexpression in PC12 cells did not protect against oxygen-glucose deprivation, the calcium ionophore A23187, or the nitric oxide donor sodium nitroprusside, suggesting that gas7 is not neuroprotective. The ability of gas7 to potentiate neuronal differentiation makes it a potential therapeutic target to promote re-establishment of neuronal connections in the injured or diseased brain, such as following stroke.