Early enteral feeding following major abdominal surgery for recurrent gynaecological cancer.

We studied the safety of early postoperative enteral feeding in 22 patients with recurrent gynaecological cancer who underwent major abdominal surgery including extensive adhesiolysis, bowel resection and bowel anastomosis. A total of 19 patients (86.4%) had been treated by both radical surgery and radiation therapy with curative intent. In 18 cases (81.8%), the indication for surgery was bowel obstruction. Preoperative total parenteral nutrition (TPN) was not used. Enteral feeding was given through a gastrostomy tube or a jejunal feeding tube and was commenced within 72 h of completion of surgery. The age range was 30-78 years with a median of 52.8 years. A total of 13 patients (59.1%) had a bowel resection and 17 patients (77.3%) had a bowel anastomosis, all stapled. The median maximum tolerated full strength feeding was 50 ml/h for 18-20 h in a 24 h period and maintained for a median of 9 days. In six patients the feeding was interrupted but was re-commenced in five, in four of whom there was no further interruption of feeding. There were no anastomotic leaks and no cases of aspiration. Postoperative enteral feeding was safe in patients with recurrent gynaecological cancer who had undergone major abdominal surgery and should be considered as an alternative to TPN.

Gastrostomy tubes in patients with recurrent gynaecological cancer and intestinal obstruction.

OBJECTIVE: Women with recurrent gynaecological cancers who are not suitable for exenterative surgery commonly present with gastrointestinal dysfunction. This paper is a retrospective review of the use of gastrostomy tubes in such women. METHODS: We performed a chart review of women with recurrent gynaecological cancer who had a gastrostomy tube placed between January 1991 and April 1998. RESULTS: Thirty-nine women (mean age 53.2 years, range 17-82) had a gastrostomy tube placed. Twenty-eight (72%) had ovarian cancer, eight (21%) had cervical cancer, two had endometrial cancer and one had vaginal cancer. In 14 women a gastrostomy tube was placed as the sole procedure for palliation (11 elective, 3 emergency). In the remaining 25 women, who underwent major surgery, a gastrostomy tube was placed in anticipation of, or in the presence of, significant intestinal distension and expected prolonged post-operative ileus. Eleven women (28%) died without leaving hospital after their operation (median 11 days, range 2-36). All but one of the 28 women who left hospital had satisfactory oral intake. Twenty-one women (54%) died with the gastrostomy tube in place (median 28 days, range 2-157) and 18 (46%) had the gastrostomy tube removed (median 14.5 days, range 9-180), 13 of whom (33%) have since died (median 167 days, range 77 days-7 years). Five women (13%) are alive (median 2.2 years, range 10 months-4.5 years). There were no problems which required the gastrostomy tube to be removed. CONCLUSION: Gastrostomy tubes have an important role in the treatment of women with recurrent gynaecological cancer, allowing gastric drainage and decompression without the disadvantages of nasogastric tubes.

Modulation of the action of gonadotrophin surge-attenuating factor by gonadotrophin-releasing hormone.

Gonadotrophin surge-attenuating factor (GnSAF) is a putative non-steroidal ovarian factor which attenuates the luteinizing hormone (LH) surge in superovulated women through the reduction of the pituitary response to gonadotrophin-releasing hormone (GnRH). The mechanism of action of GnSAF on gonadotrophin secretion was further studied by investigating six normally ovulating women in two cycles--a spontaneous and a follicle-stimulating hormone (FSH)-treated cycle. The response of the pituitary to five consecutive pulses of GnRH was investigated in late follicular phase (follicle size 15 mm) of both cycles. GnRH pulses, 10 micrograms each, were injected i.v. every 2 h and LH was measured in blood samples taken before and 30, 60 and 120 min after each pulse. FSH was injected daily at the fixed dose of 225 IU starting on cycle day 2. Peak values of LH increment occurred 30 min after each pulse. However, maximal LH increment occurred in both cycles after the second GnRH dose. In the FSH cycles the response of LH to the first three pulses was significantly attenuated compared with the spontaneous cycles, while the response to the fourth and fifth pulses was similar in the two cycles. In both cycles, LH increment 30 min post GnRH (net increase above the previous value) was similar after the fourth and fifth pulses. Serum concentrations of oestradiol and immunoreactive inhibin, although higher in the FSH cycles, remained stable throughout the GnRH experimental period in both cycles. These results demonstrate that multiple submaximal doses of GnRH can override the attenuating effect of GnSAF on LH secretion.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of an increase in FSH on the production of gonadotrophin-surge-attenuating factor in women.

Gonadotrophin-surge-attenuating factor (GnSAF) is a putative nonsteroidal ovarian factor that is produced by FSH and that attenuates the LH surge in superovulated women. To study further the role of FSH in the production of GnSAF, 12 normally ovulating women were divided into two groups and investigated during two cycles: a cycle treated with placebo (control) and a cycle treated with FSH. In group 1 (n = 6), placebo (2 ml 0.9% normal saline) or FSH (450 iu) was injected i.m. on day 2 of the cycle (09:00 h). In group 2 (n = 6), placebo (2 ml 0.9% normal saline) or FSH (225 iu) was injected on the day (09:00 h) on which the dominant follicle was 14-15 mm in diameter, as measured by ultrasound (i.e. after the pituitary had been primed by endogenous oestrogen for several days). The response of LH over 30 min (delta LH) to an injection of 10 micrograms LHRH i.v. (bioassay for GnSAF in vivo) was investigated once a day in group 1, and 4, 8, 12 and 24 h after the injection of placebo or FSH in group 2. In group 1, delta LH was significantly attenuated 12 h after treatment with FSH compared with the control cycles, while serum oestradiol concentrations increased 24 h after the injection of FSH. The decrease in delta LH lasted for the period when the FSH concentration was increased (3 days). A significant decrease in the basal concentration of LH was correlated with the increase in the oestradiol concentration.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of follicle stimulating hormone treatment on the pituitary response to luteinizing hormone-releasing hormone in post-menopausal women.

To study the role of exogenous follicle stimulating hormone (FSH) in the attenuation of luteinizing hormone (LH) response to luteinizing hormone-releasing hormone (LHRH) during ovulation induction in women, 10 healthy post-menopausal women were treated with FSH (225 IU/day) for 5 days and normal saline (2 ml/day) for another 5 days. The two regimens were given consecutively in a 10 day experiment. The regimen for the first 5 days was randomly chosen and was given to the women in an alternate way. The response of LH to an i.v. injection of 10 micrograms LHRH was investigated twice on day 1 (i.e. before the onset of treatment and 12 h later) and once on days 2, 5 and 10 of the experiment (0900 h). Basal FSH and LH values before the onset of treatment on day 1 were similar in the five women who started with the saline and the five who started with the FSH regimen. Basal FSH values increased significantly during treatment with FSH, while LH and oestradiol values remained unchanged throughout the whole experiment. LH increment 30 min post-LHRH did not change significantly either during the first 24 h or during the whole experiment regardless of the starting regimen. These results demonstrate that in post-menopausal women the response of LH to LHRH is not affected by exogenous administration of FSH. It is suggested that exogenous FSH does not show activities on gonadotrophin secretion similar to those ascribed to a gonadotrophin surge attenuating factor.

Changes in pituitary response to GnRH during the luteal-follicular transition of the human menstrual cycle.

OBJECTIVE: We studied changes in pituitary response to GnRH during the luteal-follicular transition of the human menstrual cycle. DESIGN: Normally cycling women were investigated during two consecutive menstrual cycles. In each woman, GnRH tests were performed during the two LH surges and several times during the luteal-follicular transition. Data for analysis were available in all women on days -8, -6, -4, -2, -1, 1, 2, 3, 4, 5 and 7 in relation to the onset of second menstruation (day 1). PATIENTS: Five normally ovulating parous women were studied. MEASUREMENTS: Pituitary response to GnRH was calculated as the net increase in LH and FSH at 30 minutes (delta LH and delta FSH) above the basal value. RESULTS: delta LH and delta FSH showed a similar pattern of significant changes during the luteal-follicular transition. They decreased progressively from days -8 to 1 and increased on day 2. delta LH and delta FSH then decreased on days 3 and 4 and showed a further increase on days 5 and 7. In contrast to these changes, basal FSH levels increased from days -2 to 1 and remained high up to day 5, while basal LH levels showed a trend to increase only after the onset of menses. CONCLUSIONS: These results demonstrate that the increase in basal FSH secretion during the luteal-follicular transition is GnRH independent. It is suggested that LH and FSH release under the stimulation by GnRH is regulated by a common mechanism.

Positive feedback effect of oestradiol in superovulated women.

To investigate the mechanism of blockage of the luteinizing hormone (LH) surge in superovulated women, six normally ovulating women were studied in three cycles: a spontaneous cycle treated with exogenous oestrogen (oestradiol benzoate cycle), a cycle treated with follicle stimulating hormone (FSH; 225 IU/day; FSH cycle) and a cycle treated with FSH plus exogenous oestrogen (FSH + oestradiol benzoate cycle). Oestradiol benzoate was injected i.m. on cycle days 4 (0800 and 2000 h), 5 (0800 h) and 6 (0800 h) at doses of 0.5, 1.0, 2.0 and 2.5 mg respectively to achieve supraphysiological levels of serum oestradiol. Exogenous oestrogen (supraphysiological oestradiol levels) induced an LH surge in all six women in the oestradiol benzoate cycles, but failed to stimulate an LH surge in three of the six patients during treatment with FSH. In three patients treated with FSH, an LH surge was stimulated both by supraphysiological (FSH + oestradiol benzoate cycles) and 'high normal' oestradiol levels (FSH cycles), while in three patients treated with FSH only, the LH surge was blocked, although the threshold level for the positive feedback effect had been exceeded by cycle day 9. We conclude that in women, supraphysiological concentrations of oestradiol exert a positive feedback effect on LH secretion. It is suggested that the occurrence of an LH surge in cycles superovulated with FSH is not dependent on serum oestradiol concentrations, but mainly on the strength of ovarian inhibitory substances.