Comparison of salpingectomy and tubal detorsion procedures after experimental ischemia-reperfusion injury in a rat fallopian tube model: biochemical and histopathological evaluation.

OBJECTIVE: To compare salpingectomy and detorsion procedures and investigate the biochemical and histopathological changes in the fallopian tubes in the experimentally isolated fallopian tube torsion model in rats. DESIGN: Experimental study. SETTING: Experimental surgery laboratory in a training and research hospital. ANIMAL(S): Twenty-seven Sprague-Dawley rats in the reproductive period. INTERVENTION(S): Group 1, control group (n = 6); group 2, bilateral total salpingectomy group after 4 hours of tubal ischemia (n = 7); group 3: 4 hours of bilateral tubal ischemia plus 1 week of reperfusion (n = 7); and group 4, 4-hour period of bilateral tubal ischemia plus 30 days of reperfusion (n = 7). A 22-gauge catheter was administered before and after surgery using methylene blue through the uterine horn of the rat to evaluate tubal patency. MAIN OUTCOME MEASURE(S): Preoperative and postoperative serum antimüllerian hormone (AMH) levels, histopathological examination of the rat tuba uterine and histopathological damage scores, antioxidant compounds (superoxide dismutase [SOD], catalase, and glutathione peroxidase [GSH-Px]), and oxidative stress end product levels (malondialdehyde [MDA] and 8-hydroxy-2'-deoxyguanosine [8-OHdG]). RESULT(S): Although a significant difference was observed in the tissue SOD, GSH-Px, MDA, and 8-OHdG values, no significant difference was observed between the groups in serum samples. The tissue SOD and tissue GSH-Px levels in group 2 significantly decreased, and a significant increase was observed in the tissue MDA and 8-OHdG values in group 2. Among the histopathological parameters, epithelial changes, vascular congestion, and the total fallopian tube mean damage score of 4 showed a significant decrease in group 4. When the methylene blue transitions before and after ischemia-reperfusion injury were compared, the values of the methylene blue transition after ischemia-reperfusion injury in groups 2-4 significantly decreased. When the serum AMH levels were analyzed, the postoperative AMH value in group 2 significantly increased. CONCLUSION(S): This study reveals that biochemical and histopathological improvement is observed in the fallopian tube tissues gradually when the detorsion procedure is performed for the necrotized tubal tissue instead of salpingectomy. Although there is restoration of epithelial integrity after reperfusion, tubal passage remains absent. CLINICAL TRIAL REGISTRATION NUMBER: This study was approved by the Local Ethics Committee for Animal Experiments of the Health Sciences University, Istanbul Hamidiye Medicine Faculty (approval number 27.05.2022-9269). The study followed the ethics standards recommended by the Declaration of Helsinki.

Current Management of Gynecologic Trauma.

INTRODUCTION: To date, there are few reports describing the management of traumatic gynecologic injuries leaving physicians with little guidance. OBJECTIVE: Describe the injury patterns and the preferred management of these injuries. METHODS: A retrospective cohort study was performed using the National Trauma Data Bank (NTDB) from years 2011 to 2013. Female patients age 16 years and older with internal gynecologic injuries were identified based on diagnosis codes. Demographics, associated diagnoses and procedure codes were compiled for the cohort. RESULTS: 313 patients met inclusion criteria. The mechanism of injury was blunt in 236 (75%) patients, penetrating in 68 (21%), and other in 9 (4%). The mean Injury Severity Score was 16.6 ± 14.6. Mean age was 34 ± 21 years old. 226 (74.8%) patients had an ovarian and/or fallopian tube injury, 71 (25.2%) had a uterine injury, 8 (3%) had both, and 8 (3%) had injury to the ovarian or uterine vessels only. Of the 226 patients with ovarian and/or fallopian tube injury, 11(5%) underwent repair and 10 (4%) underwent salpingo-oophorectomy. Of the 71 uterine injuries, 15 (21%) underwent repair and 5 (7%) required a hysterectomy. CONCLUSIONS: Most traumatic internal gynecologic injuries result from blunt mechanism. Currently, these injuries are largely managed non-operatively. When surgery was performed, ovarian and uterine repair was more common than salpingo-oophorectomy and hysterectomy. Prospective large-scale studies are needed to establish a standard of treatment for the management of gynecologic trauma and to assess both short and long term outcomes and fertility rates.

Two-dose versus single-dose methotrexate for treatment of ectopic pregnancy: a meta-analysis.

OBJECTIVE: To compare the treatment success and failure rates, as well as side effects and surgery rates, between methotrexate protocols. DATA SOURCES: PubMed, Embase, and the Cochrane library searched up to July 2018. STUDY ELIGIBILITY CRITERIA: Randomized controlled trials that compared women with ectopic pregnancies receiving the single-dose, two-dose, or multi-dose methotrexate protocols. STUDY APPRAISAL AND SYNTHESIS METHODS: Odds of treatment success, treatment failure, side effects, and surgery for tubal rupture, as well as length of follow-up until treatment success, were compared using random and fixed effects meta-analysis. Sensitivity analyses compared treatment success in the groups with high human chorionic gonadatropin (hCG) values and a large adnexal mass, as defined by individual studies. The Cochrane Collaboration tool was used to assess risk of bias. RESULTS: The 2-dose protocol was associated with higher treatment success compared to the single-dose protocol (odds ratio [OR], 1.84; 95% CI, 1.13, 3.00). The 2-dose protocol was more successful in women with high hCG (OR, 3.23; 95% CI, 1.53, 6.84) and in women with a large adnexal mass (OR, 2.93; 95% CI, 1.23, 6.9). The odds of surgery for tubal rupture were lower in the 2-dose protocol (OR, 0.65; 95% CI, 0.26, 1.63), but this was not statistically significant. The length of follow-up was 7.9 days shorter for the 2-dose protocol (95% CI, -12.2, -3.5). The odds of side effects were higher in the 2-dose protocol (OR, 1.53; 95% CI, 1.01, 2.30). Compared to the single-dose protocol, the multi-dose protocol was associated with a nonsignificant reduction in treatment failure (OR, 0.56; 95% CI, 0.28, 1.13) and a higher chance of side effects (OR, 2.10; 95% CI, 1.24, 3.54). The odds of surgery for tubal rupture (OR, 1.62; 95% CI, 0.41, 6.49) and time to follow-up (OR, -1.3; 95% CI, -5.4, 2.7) were similar. CONCLUSION: The 2-dose methotrexate protocol is superior to the single-dose protocol for the treatment of ectopic pregnancy in terms of treatment success and time to success. Importantly, these findings hold true in patients thought to be at a lower likelihood of responding to medical management, such as those with higher hCGs and a large adnexal mass.

Risk of hysterectomy and salpingectomy or oophorectomy compared to repair after pelvic gynecologic trauma.

PURPOSE: Pelvic gynecologic trauma (PGT) includes injury to the uterus, ovaries or fallopian tubes. We hypothesized Injury Severity Score (ISS) ≥ 25, hypotension on admission and age ≥ 51 (average age for menopause) would be independent risk factors for resection compared to repair. METHODS: A retrospective analysis of the National Trauma Data Bank was performed between 2007 and 2015. RESULTS: Of 2,040,235 female patients, 1938 (< 0.1%) presented with PGT with the majority sustaining injury to the ovary or fallopian tubes (52.9%). Most patients were managed nonoperatively (77.1 vs 22.9%). On multivariable analysis, in patients with injury to the uterus, ISS ≥ 25 (OR 3.52, CI 1.67-7.48, p < 0.05) was associated with higher risk for hysterectomy compared to repair. In patients with injury to the ovaries or fallopian tubes, gunshot wound (OR 3.73, CI 1.43-9.68, p < 0.05) was associated with a higher risk for salpingectomy or oophorectomy compared to repair. Age ≥ 51 and hypotension on admission were not independent risk factors for resection in patients with PGT. Operative treatment was associated with a lower risk for mortality in patients with an injury to the uterus (OR 0.27, CI 0.14-0.51, p < 0.001) or ovaries/fallopian tubes (OR 0.37, CI 0.19-0.72, p < 0.001) compared to those managed nonoperatively. CONCLUSION: In the largest study reported, PGT occurred in < 0.1% of traumas involving women. Patients with ISS ≥ 25 have higher risk for hysterectomy compared to repair. Gunshot injuries have higher risk for salpingectomy or oophorectomy compared to repair. Hypotension on arrival or age ≥ 51 are not independent risk factors for resection in PGT. Operative management is associated with lower risk of mortality in PGT patients.

Imaging findings in Essure-related complications: a pictorial review.

Tubal sterilization with Essure inserts has become a prevalent alternative to laparoscopic sterilization because of its minimal invasiveness. It is a well-tolerated ambulatory procedure that provides reliable permanent contraception without the risks associated with laparoscopic surgery and general anesthesia. Correct positioning of the Essure device is necessary to achieve the fibrotic reaction induced by the polyethylene terephthalate fibers, subsequently resulting in tubal occlusion usually within 3 months. After uneventful procedures with satisfactory bilateral placement, only the correct position of the devices needs to be confirmed at follow-up. The imaging techniques used to asses Essure devices may vary depending on the country and its recommendations. The gold-standard test to ascertain tubal occlusion remains the hysterosalpingography but after uneventful procedures, vaginal-ultrasound proved to be a reliable alternative to confirm the proper position of the inserts. Radiologists have been increasingly confronted to post-procedural evaluations and despite the efficiency rate of the Essure device, its use still exposes to a low risk of complications and malfunctions such as unwanted pregnancies, device misplacement, tubal or uterine perforation, and chronic pelvic pain. Unintended pregnancies are mostly due to patient or physician non-compliance and misinterpretation of post-procedural examinations by radiologists which emphasizes the importance of their training in Essure device assessment. This pictorial review discusses the imaging methods used to asses Essure implants and illustrates the possible complications related to them.

Acute intestinal obstruction due to extrinsic compression by previa myoma and ectopic pregnancy: a case report.

BACKGROUND: Acute intestinal obstruction during pregnancy is a rare digestive surgical emergency with significant maternal and fetal mortality. Diagnosis is difficult, often delaying the management. Here, we report an exceptional association of mechanical acute intestinal obstruction due to compression by previa uterine leiomyoma, and a ruptured ectopic pregnancy. CASE PRESENTATION: This is the case report of a 43-year-old primiparous black woman from a rural area, who was admitted to the surgical emergency department for acute intestinal obstruction. At examination on admittance, our patient had a bad general condition with clinical anemia. She had an occlusive syndrome that had been evolving for 3 days. A physical examination of her abdomen showed a widespread distension with an irregular and polylobed solid mass occupying the whole of the lower-umbilical and hypogastric area. A rectal examination found an empty rectum, and the mass was perceptible in Douglas's pouch. At the vaginal examination, we found the same mass and a finger holster was clean. The diagnosis of intestinal occlusion by a tumor was retained. The laparotomy revealed a distended intestine, a ruptured right tubal ectopic pregnancy and a polymyomatous uterus. The most massive previa leiomyoma was adhering and compressing the rectal and sigmoidal hinge. A total hysterectomy was performed and histopathological examination of specimens confirmed myoma and ectopic pregnancy. The surgical follow-up was uneventful, and our patient was discharged on postoperative day 12. CONCLUSIONS: The etiological diagnosis of acute intestinal obstruction during pregnancy is not easy, especially in the context of a low-income country where the means of biological and radiological diagnosis are lacking. A laparotomy is required before diagnosis of acute surgical abdomen and its management will depend on the intraoperative findings and the condition of the patient.

Regeneration of the Fallopian Tube Mucosa Using Bone Marrow Mesenchymal Stem Cell Transplantation After Induced Chemical Injury in a Rat Model.

In this study, we describe a novel insight about the use of bone marrow-derived mesenchymal stem cells (BM-MSCs) for fallopian tube (FT) regeneration. Seventy rats' tubes were involved in this study and divided into 4 groups: control (15), ethanol injured (20), mesenchymal stem cell (MSC)-recipient without injury (15), and MSC recipient after injury (20). The BM-MSCs were isolated from male rats, and their incorporation into the tissues was confirmed by the detection of Sry gene in MSC-recipient rats using RT-PCR. Histological and immunohistological sections of the 4 groups were comparably evaluated. We found that direct injection of ethanol into FT caused structural impairment, which was restored largely after receiving MSCs. We have revealed for the first time that prominin 1 (Prom1, stem cell marker) was expressed in the fimbriated distal tubal end. The MSC transplantation caused (1) significant increase in the tissue level and immunoexpresstion of Prom1 ( P < .001 and P = .017, respectively) and vascular endothelial growth factor (VEGF; vasculogenic marker; P < .001 and P = .004, respectively), (2) significant increase in the immunoexpresstion of proliferating cell nuclear antigen (PCNA; proliferation marker; P < .001), and (3) significant decrease in the immunoexpresstion of caspase 3 (CASP-3; apoptotic marker; P < .001) compared to the injured tissues. In conclusion, MSCs could exhibit its restorative effect on FT through their ability to (1) activate the resident stem cells in the distal tubal end, (2) mediate the expression of VEGF and PCNA, and (3) influence tissue apoptosis. This study laid the foundation for assessing the contribution of stem cells in the distal tubal end in direct repair of the tube when required to assist reproduction.

Spontaneous heterotopic triplets - A review of literature.

OBJECTIVE: Spontaneous heterotopic triplets, a tubal ectopic pregnancy and a twin pregnancy, are rare disorders. The study aimed to examine all available evidence regarding signs and symptoms, imaging findings, management and newborn outcome of spontaneous heterotopic triplets. DESIGN: A literature search in Medline and EMBASE databases from 2000 to 2016 was conducted. The following key words were employed: 'spontaneous heterotopic pregnancy', OR 'heterotopic triplets'. Only cases of spontaneous heterotopic triplets without assisted reproduction techniques were included. RESULTS: Six cases were identified and included in the present review. All cases presented with abdominal pain and one case presented in shock. Hemoperitoneum was present in five cases. Laterouterine mass with adnexal gestational sac is not systematically described (3 cases/6), but was a good ultrasonographic sign of heterotopic pregnancy. All patients had tubal rupture, but anyone had vaginal bleeding. The surgical treatment was made by salpingectomy in five cases to ensure successful treatment. The mean and median gestational age at delivery were 29.9 and 37.54 weeks, respectively (range 6-41 weeks). The neonatal outcome was good for 6 newborns. CONCLUSION: Spontaneous heterotopic triplets are rare. Early surgical intervention is the key to successful treatment of heterotopic triplet pregnancy and allows good neonatal outcome.

[What signs should you look for ultrasound (2D/3D) to affirm the good location of tubal implants? About a retrospective study of 92 cases]. / Quels signes échographiques doit-on rechercher (2D/3D) pour affirmer la bonne localisation des implants tubaires ? À propos d'une étude rétrospective de 92 cas.

OBJECTIVE: The aim of this study is to propose an analysis of the route and the curvature of the Essure® system in 3D ultrasound to determine their correct location so as not to miss a tubal perforation. METHODS: This is a retrospective single center study during 2 years analyzing 92 3D ultrasound performed by a single sonographer. Implant placement was performed by different operators. One prescribed 3D ultrasound control in case of difficulties with the installation; other indications where systematics. RESULTS: The Essure®'s position is right in 79% of cases. Twenty-eight implants appear incorrectly positioned on ultrasound 3D positioning. Abnormalities found are those described by the classification proposed in the literature. In one case, the curvature of the implant, not taking into account this classification, allowed to evoke a tubal perforation. Among the 28 cases of non-visualized implants in place, 3 cases of wrong position of the implant were confirmed by additional examinations (laparoscopy or HSG). For 14 cases, the ASP or HSG disproved the wrong position of the implants. In other cases, we did not have other complementary examinations. CONCLUSION: Ultrasonography 3D seems to be the method of choice to control implants for simple implementation and good reproducibility. However, the interpretation of 3D ultrasound images is sometimes difficult. The study of the curvature of the implant should be systematically analyzed not to miss a tubal perforation.

A new tubal classification system for fertility prognosis after laparoscopic salpingostomy for tubal pregnancy.

OBJECTIVE: To assess the objectivity and accuracy of a new system that predicts the pregnancy outcomes in patients with tubal pregnancy after laparoscopic salpingostomy. STUDY DESIGN: 480 tubal pregnancy patients were retrospectively stratified as mild, moderate, or severe group according to the new tubal classification system in which pelvic adhesions, tubal morphology, structure, and patency were included. The follow-up was performed for 24 months to determine spontaneous pregnancy outcomes. RESULTS: The tubal classification was significantly associated with intrauterine pregnancy rates (mild 70.9% vs. moderate 66.0% vs. severe 41.8%, P=0.001) and recurrent ectopic pregnancy rates (mild 2.8% vs. moderate 4.2% vs. severe 10.9%, P=0.047). The 24-month cumulative rate of intrauterine pregnancy was 73.5% in the mild group, 68.5% in the moderate group, and 45.8% in the severe group (P=0.002). The 24-month cumulative repeat ectopic pregnancy rate was 6.6% in the mild group, 9.1% in the moderate group, and 15% in the severe group (P=0.154). In Cox multivariate regression analysis, a lack of a history of infertility [hazard ratio (HR)=0.633, P=0.001] and tubal scoring (mild HR=2.408, P=0.008; moderate HR=2.147, P=0.010) were significantly associated with a higher rate of spontaneous intrauterine pregnancy. Having a history of infertility (HR=0.351, P=0.037) and no prior abdominopelvic surgery (HR=2.907, P=0.014) were significantly associated with a lower ectopic pregnancy rate. CONCLUSION: The new tubal classification system significantly correlated with spontaneous pregnancy outcomes in patients with tubal pregnancy following laparoscopic salpingostomy.

Patient Outcomes Following Injury from Hysteroscopic Sterilization.

OBJECTIVE: We present clinical data on two patients who underwent hysteroscopic sterilization (HS) 11 years apart using the Essure® (Bayer Inc., Whippany, NJ) device. MATERIALS AND METHODS: Symptoms and resolution are described for symptomatic Essure® patients. RESULTS: Case 1 (G3P1) underwent HS in 2004 at age 21. Performed in a physician's office without anesthesia, HS involved placement of >2 Essure® devices which was followed by severe, unrelenting pelvic pain. Confirmatory hysterosalpingogram (HSG) three months after HS revealed five devices. Surgical costs for laparoscopic assisted vaginal hysterectomy (LAVH) were fully reimbursed by the device manufacturer seven months later. Case 2 (G8P4) underwent HS in 2015 at age 32. One year earlier, the patient's right fallopian tube was removed due to ectopic pregnancy. Essure® devices were placed bilaterally in a physician's office without anesthesia; HS was accompanied by sharp pelvic pain. The patient obtained HSG three weeks after HS due to constant discomfort. Bilateral tubal occlusion was verified, but abnormal device loop configuration suggesting myometrial penetration was noted on the right. At laparoscopy, the left Essure® device was excised intact but the right coil could not be located. Thus far, there has been no offer in Case 2 from the device manufacturer to offset medical expenses. CONCLUSIONS: While HS has been FDA approved for use in the United States since 2002, this is the first description of clinical sequela when FDA labeling for the Essure® procedure is ignored. These cases illustrate the importance of proper physician training in HS and underscore the need for improved tracking of Essure® associated symptoms.

Serous tubal intraepithelial carcinoma, chronic fallopian tube injury, and serous carcinoma development.

Ovarian carcinoma is the deadliest gynecological malignancy. Previous studies have suggested that the fallopian tube may be the primary site for high-grade serous carcinoma. In prophylactic salpingo-oophorectomies from women with hereditary high risk for ovarian cancer, precursors can be assessed prior to onset and studied as a model for serous cancer precursor lesions. Epidemiologic studies indicate that carcinogenesis may be a result of chronic fallopian tube injury. The aims of this study were to (1) to examine the incidence of serous tubal intraepithelial carcinoma (STIC) in relation to other clinical parameters and (2) to evaluate whether chronic fallopian tube injury was related to cancer development. This study enrolled 101 women, comprising the following three groups: hereditary (n = 60), sporadic serous cancer (n = 18; endometrial cancers were excluded), and control (n = 23). The cases were histologically examined and clinical risk factors were collected. The histological changes were compared between different patients and correlated to clinical risk factors. STICs were identified primarily on the fallopian tube fimbria. The incidence of STIC was 3 % in the hereditary patients. In sporadic serous cancer cases, 61 % were associated with STIC and tubal carcinoma (p < 0.001). No differences in tubal injury or inflammation were seen when comparing the sporadic serous cancer group and the control group or within the hereditary group. STIC and invasive cancer were seen more often in the older patients than in the younger patients (p = 0.528). This small study, no correlation with chronic tubal injury or inflammation was identified.

Infarto tubárico por torsión aislada de trompa de Falopio: presentación de un caso / Tubal infarction due to isolated torsion of a Fallopian tube: A case report

La torsión tubárica es una causa muy rara de abdomen agudo en mujeres, especialmente en edad fértil. La falta de síntomas o hallazgos clínicos patognomónicos así como su escasa incidencia la hacen difícil de diagnosticar, lo que retrasa el manejo precoz para poder preservar la trompa. Presentamos aquí un caso clínico representativo de esta dolencia

Tubal torsion is a rare cause of acute abdomen in women, especially those of childbearing age. Because of the lack of pathognomonic symptoms, clinical findings, and their low incidence, diagnosis is difficult, which delays early management and hampers tubal preservation. We report a representative case of tubal torsión

Management of perforated essure with migration into small and large bowel mesentery.

The Essure permanent birth control system (Conceptus Inc, San Carlos, CA) is currently the only Food and Drug Administration-approved hysteroscopic sterilization method and has been widely accepted as a safe and effective procedure. We present a rare case of tubal perforation, coil fragmentation, and distal migration into small and large bowel mesentery 8 days after the insertion of the Essure device. We describe the successful management of this complication using laparoscopy and intraoperative fluoroscopy. Providers using Essure must be aware of the possibility of fragmentation of the Essure coils. Intraoperative imaging, ideally fluoroscopy, should be strongly considered in the management of Essure migration to ensure localization and full retrieval of Essure material.

Novel reversible permanent contraception: an animal experiment of embedding contraceptive surgery in the fimbriated extremity of the fallopian.

AIM: According to female pelvic anatomical characteristics, we designed a novel reversible permanent contraception: embedding contraceptive surgery in the fimbriated extremity of the fallopian. This study involves embedding the oviduct of New Zealand rabbits into the peritoneum, and assesses contraceptive effect, morphological changes and recoverability. METHODS: Thirty New Zealand rabbits were divided into three groups: embedding in the fimbriated extremity of the fallopian group (A group); polyethylene film in the fimbriated extremity of the fallopian group (B group); and control (C group). Surgery was performed in each group, respectively. Contraceptive efficacy, morphological changes and recoverability were noted. RESULTS: As for contraceptive effect, mating experiences were successful. After 3 months, there were no pregnant rabbits in group A and B, while in group C all samples were pregnant. Regarding recoverability, after belly operation, 10 rabbits in group A showed dropsy in the bilateral oviducts. Tissue adhesion could be found in the fimbriated extremity of the fallopian with a large range of damage. All samples in group B also had dropsy, but only two of them had unilateral slight adhesions in the fimbriated extremity of the fallopian, while others had no pathological changes. After being released from the oviduct embedding, five rabbits in group A became pregnant and nine in group B. CONCLUSION: Embedding contraceptive surgery in the fimbriated extremity of the fallopian after being covered by polyethylene film is reliable and safe. Releasing the embedding may cause minor injury. Although there is a problem of hydrosalpinx, the pregnancy rate is high.

[Interest of 3D ultrasound in the follow-up of tubal sterilizations: case report of a rare tubal perforation]. / Intérêt de l'échographie en 3 dimensions dans le suivi des stérilisations tubaires : à propos d'un cas rare de perforation.

The Essure™ system's effectiveness is based on the follow-up at three months. The challenge is to find a minimally invasive imaging technique to locate the devices. Therefore, many authors recommend three-dimensional ultrasound in first-line. We report here an exceptional case of tubal perforation for which ultrasound failed to diagnose. Until then, only three cases have been reported in the literature, noting the difficulty to diagnose this complication. Indeed, although ultrasound is described as reliable, reproducible and non-radiating, it is a dynamic examination, operator dependent, exposing to the risk of misinterpretation.