Análisis de los factores que motivan la reconversión a laparotomía en los quistes de ovario tratados inicialmente por laparoscopia / Analysis of factors leading to conversion to laparotomy in adnexal cysts initially treated by laparoscopy

Se realiza un estudio retrospectivo, observacional y descriptivo del total de los quistes de ovario reconvertidos en el mismo acto quirúrgico de laparoscopia a laparotomía en los últimos 7 años (1999-2005) en el Hospital Universitario Joan XXIII de Tarragona. Se analizan las características de las pacientes y los posibles factores que contribuyen a un mayor riesgo para la reconversión, como la cirugía previa y afecciones como la endometriosis y el tamaño del quiste. El porcentaje de reconversión es de un 8,6%. Las causas fueron cuadros adherenciales, 81%; hemorragia incoercible, 5,4%; dificultad anestésica, 5,4%; imposibilidad de realizar el neumoperitoneo, 5,4%, y fallo en el material, 2,7%. La anatomía patológica más frecuente en estos casos fue de endometriosis en un 67,5% de los casos (AU)

A descriptive, observational, retrospective study was performed of patients with cystic adnexal masses who required conversion from laparoscopic to open surgery in the same intervention in a 7-year period (1999-2005). The study was carried out in the Joan XXIII University Hospital in Tarragona, Spain. Patient characteristics and the possible factors contribut ing to a higher risk of failed laparoscopy, such as prior surgery, the presence of endometriosis, and cyst size, were analyzed. Conversion to laparotomy occurred in 8.6% of all patients and was associated with adhesions in 81%, incoercible bleeding in 5.4%, anesthetic difficulties in 5.4%, impossibility of performing pneumoperitoneum in 5.4% and equipment failure in 2.7%. Endometriosis was found in 67.5% of the total number of cysts (AU)

Metástasis endometrial de carcinoma lobulillar de mama / Endometrial metastases from lobular carcinoma of the breast

El sangrado de origen uterino en la mujer posmenopáusica nos hace pensar, de forma inmediata, en descartar un proceso maligno. En el caso de mujeres con antecedente de neoplasia primaria de otro origen hay que descartar la posibilidad de la metástasis uterina. Se presentan 2 casos de neoplasia de mama conocida, carcinoma lobulillar de tipo clásico, que evolucionaron con metástasis uterina. Uno de ellos presentó la forma clínica habitual, el sangrado genital; pero el segundo caso se diagnosticó de forma casual en un control del cáncer de mama. Se comenta el diagnóstico diferencial, así como la necesidad de la utilización rutinaria de las técnicas de imagen en las pacientes con cáncer de mama

Vaginal bleeding in postmenopausal women automatically suggest the presence of a malignant process. In women with a history of cancer, the possibility of uterine metastases must be ruled out. We report 2 cases of lobular carcinoma of the breast metastatic to the uterus. The first case presented as vaginal discharge, but the other was a chance finding in a routine follow-up visit. We discuss the differential diagnosis of this process and the need for the routine use of imaging modalities in the follow-up of patients with breast cancer

¿Es posible reducir la estancia en cirugía ginecológica benigna mediante la utilización de protocolos de asistencia? / Can hospital stay after surgery for bening gynecological processes be reduced by the use of protocols?

Objetivo: Demostrar que una adecuada protocolización de la asistencia quirúrgica y posquirúrgica permite disminuir la estancia hospitalaria en la cirugía ginecológica laparotómica benigna sin aumentar la morbilidad y manteniendo los estándares de calidad. Pacientes y método: Comparamos la estancia media hospitalaria de dos grupos homogéneos de pacientes: uno control de 54 pacientes y otro de estudio de 53, con procesos benignos ginecológicos a las que se practicó cirugía la parotómica. Al grupo de estudio se le sometió a un protocolo definido para facilitar el alta lo más tempranamente posible. Resultados: Ambos grupos fueron comparables respecto al tipo de ingreso, de cirugía practicada, comorbilidad, complicaciones y situación al alta. La estancia preoperatoria no evidenció diferencia significativa (p = 0,20). La estancia hospitalaria fue de 7,8 días para el grupo control y de 6,1 para el de estudio, existió una diferencia significativa entre ambos (p = 0,004). En ninguno de los grupos se presentó reingreso antes de 30 días ni relacionados. No se registraron reclamaciones ni sugerencias relacionadas con la duración de la estancia en atención al paciente. Conclusiones: Resulta posible una reducción de la estancia hospitalaria posquirúrgica para procedimientos ginecológicos, y ésta actúa de forma adecuada sobre los protocolos de cuidados postoperatorios (AU)

Síndrome de transfusión feto-fetal / Twin-twin transfusion syndrome

El síndrome de transfusión feto-fetal (STFF) es una complicación que se presenta en un 10-15 per cent de las gestaciones gemelares monocoriales biamnióticas. Es una afección exclusiva de este tipo de gemelaridad y se caracteriza por la presencia de anastomosis arteriovenosas cuyo flujo unidireccional no está equilibrado por otras conexiones vasculares y, por consiguiente, se produce la secuencia oligoamnios-hidramnios. La afección fetal es debida a una hipovolemia del gemelo donante y a una hipervolemia del gemelo receptor. Presentamos nuestra experiencia en este tipo de enfermedad. En los casos presentados, diagnosticados al final del segundo trimestre, se llevaron a cabo como medida terapéutica amniodrenajes seriados, los cuales permitieron prolongar la gestación para la maduración pulmonar fetal, aunque no solucionaron el STFF. Realizamos, asimismo, una revisión en cuanto a las diferentes opciones de tratamiento actual que van desde la conducta expectante, con una mortalidad cercana al 100 per cent, hasta los tratamientos etiológicos basados en la ablación selectiva con láser de los vasos comunicantes con una supervivencia de al menos un gemelo del 70 per cent, con una tasa de handicap neurológico menor al 5 per cent. (AU)

Tissue factor levels and high ratio of fibrinopeptide A:D-dimer as a measure of endothelial procoagulant disorder in pre-eclampsia.

To assess coagulation activation and endothelial cell injury in normotensive and pre-eclamptic pregnant women, a comparison was made of plasma levels of tissue factor, fibronectin, fibrinopeptide A and D-dimer. Samples were taken from 50 nonpregnant women, 40 normotensive pregnant women in the third trimester and 27 women with pre-eclampsia after diagnosis and before treatment. High levels of fibrinopeptide A and D-dimer were found in pre-eclamptic women. Moreover, the ratio fibrinopeptide A:D-dimer was much greater in the pre-eclampsia group than in normotensive pregnant women. The levels of fibronectin and tissue factor were also higher in the pre-eclampsia group. The increase of tissue factor levels suggests an alteration of the extrinsic coagulation pathway in pre-eclampsia. The increase of fibrinopeptide A:D-dimer ratio shows that the activation of coagulation is associated with a relative hypofibrinolysis in pre-eclampsia.

Endothelial cell lesion in preeclampsia. Morphofunctional study using umbilical endothelial cells.

Morphofunctional study of umbilical cords from pregnancies complicated by preeclampsia shows both activation and lesion of endothelium. The cellular findings in umbilical cords from pregnancies complicated by preeclampsia can be summarized as: (i) higher number of cells with secretion bladders and increase in the number and size of both secretion bladders and microvilli-like protrusions; (ii) increase in collagen, fibrin, fibronectin and lipidic vesicles in the vessel wall; (iii) vacuolization of endothelial cells; (iv) presence of lipidic vacuoles and lipophages in the vessel wall; (v) erosion and disorganisation of the endothelium that exposes extracellular proteins to the blood flow. Endothelial cell cultures from preeclamptic pregnancies show kinetic disorders and cell detachment. The results confirm that an endothelial cell lesion occurs in preeclampsia and this cellular disorder can be reproduced in vitro.

Coagulation and fibrinolysis parameters in normal pregnancy and in gestational diabetes.

The changes in coagulation and fibrinolysis parameters during pregnancy, delivery and 3 days after delivery were evaluated in normotensive and gestational diabetes pregnant women. Normal pregnant women (n = 60) and pregnant women with gestational diabetes (n = 15) formed the study population. Coagulation and fibrinolysis parameters were estimated using commercial tests. Antithrombin III, thrombin-antithrombin III complexes, heparin cofactor II, protein C, protein S, tissue plasminogen activator, (t-PA) D-dimer and plasminogen activator inhibitor (PAI-1 and PAI-2) activities in normal and gestational diabetes pregnancies were determined. Thrombin-antithrombin III complexes increased and coagulation inhibitors decreased in gestational diabetes. Plasminogen activator inhibitors remained unchanged and t-PA levels increased in gestational diabetes.

Endothelial cell markers and fibrinopeptide A to D-dimer ratio as a measure of coagulation and fibrinolysis balance in normal pregnancy.

OBJECTIVE: Changes in hemostatic system were evaluated in healthy pregnant women. METHODS: Blood was sampled in the 1st, 2nd and 3rd trimesters of gestation, during delivery and 3 days postpartum and plasma factors were measured using commercial tests. RESULTS: Thrombin-antithrombin III complexes, fibrinopeptide A and D-dimer were higher during pregnancy. The endothelial cell markers, fibronectin and tissue factor, remained within the normal reference values in the healthy nonpregnant population. This result suggests no endothelial injury and shows no activation of extrinsic coagulation pathway during pregnancy. The balance coagulation/fibrinolysy is maintained during pregnancy and delivery, as shown by the ratio fibrinopeptide A/D-dimer, however, a tendency towards coagulation process is developed in the early puerperium.

Heparin cofactor II: a new marker for pre-eclampsia.

The plasma levels of heparin cofactor II were determined in pregnant women who were either normotensive, or had essential hypertension, gestational hypertension or pre-eclampsia during the third trimester and 72 h after delivery. Heparin cofactor II levels in the pre-eclampsia group were depressed. The clinical relevance of this finding is the potential utility of heparin cofactor II plasma levels in the differential diagnostic between non-proteinuric hypertension and pre-eclampsia.

Coagulation and fibrinolytic parameters in normal pregnancy and in pregnancy complicated by intrauterine growth retardation.

The objective of this article is to evaluate the plasma levels of coagulation and fibrinolysis parameters in the third trimester of gestation and 72 hr postdelivery. Antithrombin III (ATIII), thrombin-antithrombin III complexes (TAT), heparin cofactor II (HCII), protein C (PC), protein S (PS), tissue plasminogen activator (t-PA), D-dimer, and plasminogen activator inhibitors (PAI-1 and PAI-2) levels in uncomplicated pregnancies and in pregnancies complicated by intrauterine growth retardation (IUGR) have been determined. Normal pregnant women (n = 63) and women whose was complicated by IUGR (n = 10) formed the study population. Coagulation and fibrinolysis parameters were estimated using commercial tests. There were no differences in ATIII, HCII, and PS levels between normal and IUGR pregnancies. TAT, t-PA, and D-dimer levels were higher in IUGR pregnancy than in the uncomplicated pregnancy group. PAI-1 and PAI-2 were found depressed in IUGR pregnancy when compared with normal pregnancy. Changes in coagulation and fibrinolytic systems occur in plasma of women with pregnancies complicated by IUGR. The results suggest an activation of the coagulation system in pregnancies complicated by IUGR. Reduced PAI-2 and high TAT levels correlate with birth weight. In IUGR pregnancies a hypercoagulative state with hyperfibrinolytic compensatory mechanisms is suggested.

Fibrinolysis changes in normal pregnancy.

The aim of this study was to evaluate the changes in fibrinolysis parameters during pregnancy. Normal pregnant women (n = 60) formed the study population. Blood samples were taken in the first, second and third trimester, during delivery and three days after delivery. Fibrinolysis parameters were estimated using commercial tests. Tissue plasminogen activator, D-dimer and plasminogen activator inhibitors (PAI-1 and PAI-2) were determined. Tissue plasminogen activator and D-dimer increased after the first trimester and reached maximum levels during delivery. Plasminogen activator inhibitors type 1 and type 2 were also higher, in particular PAI-2, and reached maximum levels in the third trimester. On the third day after delivery, fibrinolysis activity recovered, but D-dimer and PAI-2 levels remained above the normal non-pregnant range.

Pelvic masses and endoscopic surgery: diagnosis.

Most adnexal masses are benign but a careful preoperative evaluation is necessary to exclude malignancy. Pelvic examination is considered to be of limited importance Ultrasonography is of prime importance and also tumor marker's assays. The last step of evaluation to exclude malignancy is the laparoscopic inspection of the tumor. If any signs of malignancy are found, laparotomy is performed immediately. The majority of patients with a benign adnexal cyst can be treated by operative endoscopy.

Metastatic cancer spread at the laparoscopic puncture site. Report of a case in a patient with carcinoma of the ovary. Case report.

The aim of this study is to draw attention to the possibility of the occurrence of a metastatic spread at the laparoscopic entrance site in patients suffering from a carcinoma of the ovary. This event has rarely been mentioned in medical literature before. A case is presented here in which a localized tumoral lesion appeared after a laparoscopic staging study in the abdominal wall, exactly at the site used for the introduction of the accessory laparoscopic trocar in a patient suffering from a carcinoma of the ovary.