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Importance: The formation of adhesions after gynecological surgery not only has detrimental impacts on those affected, including pain, obstruction, and infertility, but also imposes a high economic burden on healthcare systems worldwide. Objective: The aim of this review was to evaluate the adhesion prevention potential of all currently available adhesion barriers for gynecological surgery. Evidence acquisition: We systematically searched MEDLINE and CENTRAL databases for randomized controlled trials (RCTs) on the use of adhesion barriers as compared with peritoneal irrigation or no treatment in gynecological surgery. Only RCTs with second-look surgery to evaluate adhesions in the pelvic/abdominal (but not intrauterine) cavity were included. Results: We included 45 RCTs with a total of 4,120 patients examining a total of 10 unique types of barriers in second-look gynecological surgery. While RCTs on oxidized regenerated cellulose (significant improvement in 6 of 14 trials), polyethylene glycol with/without other agents (4/10), hyaluronic acid and hyaluronate + carboxymethylcellulose (7/10), icodextrin (1/3), dextran (0/3), fibrin-containing agents (1/2), expanded polytetrafluoroethylene (1/1), N,O-carboxymethylchitosan (0/1), and modified starch (1/1) overall showed inconsistent findings, results for expanded polytetrafluoroethylene, hyaluronic acid, and modified starch yielded the greatest improvements regarding adhesion reduction at 75%, 0–67%, and 85%, respectively. Conclusions and relevance: Best results for adhesion prevention were reported after applying Gore-Tex Surgical Membrane, hyaluronic acid, and 4DryField®. As Gore-Tex Surgical Membrane is nonabsorbable, it is associated with a greater risk of new adhesion formation due to second-look surgery to remove the product. 4DryField® yielded the greatest improvement in adhesion score compared to all other barrier agents (85%). For better comparability, future studies should use standardized scores and put more emphasis on patient-reported outcome measures, such as pain and infertility. [ABSTRACT FROM AUTHOR]

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Copyright of Die Gynäkologie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

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Copyright of Colo-Proctology is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Introduction: Early endometrial cancer is primarily treated surgically via hysterectomy, adenectomy and, depending on tumor stage and subtype, lymphadenectomy. Systematic lymph node dissection is known to cause surgical complications. The aim of the present study was to investigate morbidity and mortality rates associated with lymphadenectomy in patients with endometrial cancer who underwent surgery in a routine clinical setting. Methods: We collected data from 232 patients who were operated for endometrial carcinoma between 2006 and 2018 at the University of Lubeck, Germany. Surgical complications were viewed in relation to surgical risk factors. Additionally, a questionnaire concerning long-term lymphatic complications and survival was completed. Survival was compared between patients who underwent lymphadenectomy (group I) and those who did not (group II). Results: Patients in group I needed revision surgery significantly more often due to postoperative complications (such as lymphoceles) compared to those in group II (p = 0.01). The results indicate more serious complications in patients who underwent a systematic lymphadenectomy and in those with lymph node metastases. 15% of patients who underwent a systematic lymphadenectomy had lymph node metastases. Recurrences occurred in 12.5% of cases and were significantly more frequent in patients who had undergone a lymphadenectomy, even if the lymph nodes were negative (p = 0.02). A comparison of survival data during the follow-up period revealed no significant difference. The study highlighted the need for a better preoperative risk stratification and the avoidance of lymphadenectomy for surgical staging alone. [ABSTRACT FROM AUTHOR]

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Copyright of Anaesthesist is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

No data exist concerning the appication of a new robotic system with 3 mm instruments (Senhance®, Transenterix) in infants and small children. Therefore, the aim of this study was to test the system for its feasibility, performance and safety of robotic pediatric abdominal and thoracic surgery in piglets simulating infants with a body weight lower than 10 kg. 34 procedures (from explorative laparoscopy to thoracoscopic esophageal repair) were performed in 12 piglets with a median age of 23 (interquartile range: 12–28) days and a median body weight of 6.9 (6.1–7.3) kg. The Senhance® robotic system was used with 3 mm instruments, a 10 mm 3D 0° or 30° videoscope and advanced energy devices, the setup consisted of the master console and three separate arms. The amount, size, and position of the applied ports, their distance as well as the distance between the three operator arms of the robot, external and internal collisions, and complications of the procedures were recorded and analyzed. We were able to perform all planned surgical procedures with 3 mm robotic instruments in piglets with a median body weight of less than 7 kg. We encountered two non-robot associated complications (bleeding from the inferior caval and hepatic vein) which led to termination of the live procedures. Technical limitations were the reaction time and speed of robotic camera movement with eye tracking, the excessive bending of the 3 mm instruments and intermittent need of re-calibration of the fulcrum point. Robotic newborn and infant surgery appears technically feasible with the Senhance® system. Software adjustments for camera movement and sensitivity of the fulcrum point calibration algorithm to adjust for the increased compliance of the abdominal wall of infants, therefore reducing the bending of the instruments, need to be implemented by the manufacturer as a result of our study. To further evaluate the Senhance® system, prospective trials comparing it to open, laparoscopic and other robotic systems are needed. [ABSTRACT FROM AUTHOR]

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Electromechanical morcellation—so called power morcellation—is a minimally invasive approach to remove bulky lesions such as uterine fibroids. The spread of benign and malignant tissue due to morcellation is a major concern that might limit the use of laparoscopic interventions. We present an in vitro evaluation of the safety characteristics of a four-port endobag with closable trocar sleeves, and describe physical properties of the bag that may or may not allow passage through the hole. In addition, we report our preliminary experience of this tool when used for laparoscopic supracervical hysterectomies. The behavior of the endobag during the extraction process was analyzed by extracting opened and re-sealed bags filled with 20 ml blue dye solution through a wooden template, with incisions measuring 10 to 24 mm. The endobag was used in 50 subtotal hysterectomies during the morcellation procedure. In the in vitro test, no dye loss was recorded for incisions measuring 11–24 mm. The mean force required to pull the bag through the template was inversely proportional to incision size. No bag rupture occurred during the surgical procedures. The mean time taken to prepare the bag for morcellation was 7.1 min (range, 4–14 min), the mean duration of subtotal hysterectomy was 53.4 min (range, 20–194 min). The mean weight of the removed body of the uterus was 113.8 g (range, 13–896 g), the mean weight of tissue and fluid remaining in the bag after morcellation 7.9 g (range, 0–39 g). In the in vitro setting, the improved endobag signifies greater patient safety during bag extraction, along with less tissue traumatization due to a smaller incision in the abdominal wall. The improved ergonomic features of the bag permit the insertion of three trocars in the lower abdomen and avoid closure of unused access ports. Our preliminary experience has shown that the device can be used under routine conditions. Failure rates will be evaluated in future studies. [ABSTRACT FROM AUTHOR]

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Background: Education of clinical anatomy and training of surgical skills are essential prerequisites for any surgical intervention in patients. Here, we evaluated a structured training program for advanced gynecologic laparoscopy based on human body donors and its impact on clinical practice. Methods: The three-step training course included: (1) anatomical and surgical lectures, (2) demonstration and hands-on study of pre-dissected anatomical specimens, and (3) surgical training of a broad spectrum of gynecological laparoscopic procedures on human body donors embalmed by ethanol-glycerin-lysoformin. Two standardized questionnaires (after the course and 6 months later) evaluated the effectiveness of each of the training modules and the benefits to surgical practice. Results: Eighty participants took part in 6 training courses using a total number of 24 body donors (3 trainees/body donor). Based on a 91.3% (73/80) response rate, participants rated high or very high the tissue and organ properties of the body donors (n = 72, 98.6%), the technical feasibility to perform laparoscopic surgery (n = 70, 95.9%), and the overall learning success (n = 72, 98.6%). Based on a 67.5% (54/80) response rate at 6 months, participants rated the benefit of the course to their daily routine as very high (mean 80.94 ± 24.61%, n = 53), and this correlated strongly with the use of body donors (r = 0.74) and the ability to train laparoscopic dissections (r = 0.77). Conclusions: This study demonstrates the technical feasibility and didactic effectiveness of laparoscopic training courses in a professional and true-to-life setting by using ethanol-glycerol-lysoformin embalmed body donors. This cost-efficient fixation method offers the option to integrate advanced surgical training courses into structured postgraduate educational curricula to meet both the technical demands of minimal invasive surgery and the ethical concerns regarding patients´ safety. [ABSTRACT FROM AUTHOR]

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Copyright of Ethik in der Medizin is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Upon ligand binding, plasma membrane–located TNF-related apoptosis-inducing ligand (TRAIL)–receptors 1 and 2 induce apoptosis as well as cancer-promoting signaling in cancer cells. TRAIL-R3 and TRAIL-R4 are believed to negatively regulate TRAIL-mediated apoptosis. Intracellular localization of TRAIL-receptors, as observed in many tumor cells, has been associated with oncogenic features, which are distinct from membrane-associated TRAIL-R signaling. Here, analyzing a panel of 354 breast cancer specimens, we found that an unfavorable outcome correlating with cancer-promoting properties of TRAIL-R1, TRAIL-R2, and TRAIL-R4 was most significantly defined by their intracellular distribution and mutual co-expression. A nuclear or cytoplasmic heterogeneous expression pattern correlated with markedly decreased overall survival and discriminated high-risk breast cancer patients from low-risk patients with a homogeneous distribution of expression, i.e., nuclear and cytoplasmic expression. The homogeneous TRAIL-R expression was associated with favorable breast cancer surrogate markers corresponding with excellent survival prognoses at 5 years after diagnosis (hazard ratio, 0.043) and over the complete course of follow-up (hazard ratio, 0.098; both p < 0.001). No associations with specific intrinsic breast cancer subtypes were found. Our data suggest that the determination of intracellular co-expression patterns of TRAIL-R1, TRAIL-R2, and TRAIL-R4 provides an innovative and robust method for risk stratification in breast cancer patients beyond conventional prognostic markers. Key messages: A total of 70% of breast cancer specimens show comparably high levels of intracellular TRAIL-Rs. Nuclear or cytoplasmic TRAIL-R co-expression occurs in the majority of tumors. A total of 25% of tumors show a heterogeneous expression of cytoplasmic or nuclear TRAIL-Rs. Patients with a heterogeneous TRAIL-R expression present with poor prognoses. Additive TRAIL-R-based risk stratification comprises different breast cancer subtypes. [ABSTRACT FROM AUTHOR]

Purpose: Maternal obesity is one of the most commonly occurring risk factors in obstetrics. Complications, such as gestational diabetes, venous thromboembolism, preeclampsia and many more, exist far more often in obese women than in pregnant women of normal weight.Methods: Changes in maternal weight gain during pregnancy were analysed in Schleswig-Holstein between 1995 and 1997 and between 2004 and 2009. Between 1995 and 1997 data were drawn from 74,000 singleton pregnancies and between 2004 and 2009 from 118,000 pregnancies. The data centre of the University of Rostock performed the statistical analysis.Results: Maternal weight at the time of first consultation with proof of pregnancy was 67.6 kg in 1995 and increased to 70.7 kg in 2009. This means an absolute difference of 3.1 kg. Maternal weight at the time of delivery changed from 80.8 to 84.9 kg in the same period. This is an absolute difference of 4.1 kg. Body weight is higher in 2009 than in 1995 across nearly all age groups. Even in younger women (aged 17 years and over) differences in weight can be registered. The obesity rate (BMI ≥ 30) in relation to maternal age was also analysed. In general, the rate of obesity is higher in 2009 than in 1995 across all age groups.Conclusions: These results show an increase in maternal weight gain during pregnancy over the last decades. However, the change in maternal weight is not dependent upon maternal age. The weight differences are consistent across nearly all age groups. Thus, age is not a risk factor for overweight and obesity. [ABSTRACT FROM AUTHOR]

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Copyright of Der Gynäkologe is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: Electromechanical power morcellation is an important tool of modern laparoscopy. Recent reports on the spread of previously undetected malignancy by power morcellation indicate the need for additional protective devices to reduce this risk. We conducted a study to obtain the first data concerning the safety of an endobag with three closable ports during morcellation and subsequent bag extraction under in vitro conditions, mimicking the settings in our operating theater. The second purpose of the study was to establish a minimal width of the skin incision necessary to safely extract the sealed bag after morcellation.Methods: The morcellation test was carried out on 11 stained porcine muscle tissue samples with one additional sample as a control. The insufflation pressure was set at 12 mmHg. After filling the endobag with blue dye solution, an additional extraction test was conducted by pulling the closed bag through a template with apertures of various diameters. For each opening, a series of ten bag extractions was carried out.Results: No loss of solid material or fluid was recorded during the morcellation test. The extraction test showed a loss of fluid for template openings smaller than 18 mm. The force necessary to extract the bag was inversely related to the width of the aperture.Conclusions: The data suggest that under the evaluated conditions, the use of a closable morcellation bag can considerably improve the patient's safety during morcellation. Further studies are necessary to evaluate the influence of the bag on operating time, intervention costs and complications. [ABSTRACT FROM AUTHOR]

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Purpose: To determine correlations between macrophage colony-stimulating factor (MCSF) levels in maternal blood during first trimester screening with respect to normal and pathological pregnancies.Methods: This was a prospective single centre study. First trimester screening was performed according to FMF London certificates. Nuchal translucency, PAPP-A and free β-HCG were obtained as well as M-CSF serum levels in maternal blood. Fetal karyotyping was achieved by chorionic villi sampling.Results: 125 patients were enrolled in this study. 21 pregnancies had confirmed aberrant karyotypes. Trisomy 21 cases showed significantly elevated M-CSF levels of 270 ± 91 pg/ml (p = 0.032), whereas cases of trisomy 13 (183 ± 68 pg/ml) and trisomy 18 (143 ± 40 pg/ml) had low M-CSF levels. Furthermore M-CSF levels tended to be low in preterm deliveries, placental insufficiency and nicotine consumption. In cases with gestational diabetes M-CSF tended to be elevated. Furthermore we found a positive correlation between high free β-human chorionic gonadotropin (hcg) and MCSF values. There was no correlation between pregnancy associated plasma protein (PAPP-A) and M-CSF.Conclusions: M-CSF is a cytokine promoting placental growth and differentiation. M-CSF is known to be involved in the process of implantation in pregnancy. The role of M-CSF with respect to disturbed pregnancy outcomes such as placental insufficiency in normal or aberrant karyotypes, for example, is yet subject to further research. [ABSTRACT FROM AUTHOR]

Background: Stromal fibroblasts influence tumor growth and progression. We evaluated two aldo-keto reductases, AKR1C1 and AKR1C2, in stromal fibroblasts and carcinoma cells as prognostic factors in primary human breast cancer. They are involved in intratumoral progesterone metabolism. Methods: Immunohistochemistry was performed on tissue microarrays from 504 core biopsies from breast cancer patients. Primary endpoints were disease-free (DFS) and overall (OS) survival. Results: AKR1C1 and AKR1C2 expression in fibroblasts and tumor cells correlated with favorable tumor characteristics, such as small tumor size and negative nodal status. In univariate analysis, AKR1C1 expression in carcinoma cells correlated positively with DFS und OS; AKR1C2 expression in both fibroblasts and tumor cells also showed a positive correlation with DFS and OS. In multivariate analysis, AKR1C1 expression in carcinoma cells was an independent prognostic marker. Conclusion: It can be assumed that our observations are due to the independent regulatory function of AKR1C1/2 in progesterone metabolism and therefore provide a basis for new hormone-based therapy options for breast cancer patients, independent of classic hormone receptor status. [ABSTRACT FROM AUTHOR]

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Purpose: Often breast cancer can be treated by breast-conserving surgery (BCS), after which 10 % locoregional recurrences (LRR) occur within 10 years. After BCS mastectomy is recommended at first LRR, although another BCS could be possible. Changes in clinical parameters and in tumor biology from primary breast cancer to first and multiple LRR are described and correlated with further LRR and overall survival (OS). Methods: 380 patients with ≥1 ≤3 LRR (1997-2007) were evaluated retrospectively and followed until 5/2009. Patients' age, tumor size, nodal involvement, distant metastases, histological subtype, hormone receptor (HR) and Her-2/neu status were assessed. LRR therapy options were evaluated. Results: 247 patients had one LRR (94 two and 39 three). Mean OS was 10.1 years. Number of LRR was not correlated with OS. Positive HR status was significantly correlated with longer OS. Patients, who changed from primarily ER negative to positive at first LRR had a significantly longer OS compared to those, who remained or changed to ER negative ( p < 0.01). Tumor size and grading correlated inversely with OS (both: p < 0.001). BCS at first LRR correlated with a significantly better OS than mastectomy ( p < 0.001). LRR cases with chemotherapy had a shorter OS. Irradiation and/or endocrine therapy after LRR were not correlated with OS. Conclusions: Patients with positive HR status had the best survival data. HR should always be determined. In positive cases, endocrine therapy is recommended. As clinical data are good, BCS at first LRR can be suggested for more patients. [ABSTRACT FROM AUTHOR]

Background: Hysterectomies are preformed abdominally, vaginally, laparoscopic or with robotic assistance. When choosing the route of hysterectomy, the physician should take into consideration the safest and most cost-effective route to fulfill all needs of the patient. Methods: Data were collected retrospectively from 953 patients who underwent hysterectomy between 2002 and 2010 for benign indications at UKSH, Germany. Preoperative risk scores were assigned to patients. The data were statistically evaluated to investigate relationship between the occurrence of the complication and the preoperative score at the time of the hysterectomy. For the preoperative score, patients who had undergone a previous laparoscopy were assigned 1 point; those who had undergone a previous Pfannenstiel laparotomy were assigned 2 points; those who had undergone 1 cesarean delivery were assigned 3 points; those who had undergone 2 cesarean deliveries were assigned 4 points; those who had undergone 3 cesarean deliveries were assigned 5 points; and those with no previous operations were assigned 0 points. The preoperative score was recorded for 785 patients. Results: Of the 785 women with complete data, the mean preoperative score was 1.09 ± 1.51 for AH, 0.75 ± 0.96 for VH, 1.04 ± 1.30 for LSH, 1.0 ± 1.40 for LAVH, and 1.38 ± 1.52 for TLH. The prevalent scores in the VH were 0 and 1, the LASH and TLH showed a prevalence over VH in the preoperative scores 3 and 4 and AH showed a prevalence over the other methods in the preoperative score 3-8. Intraoperative complications were recorded in 28 of 953 (2.9 %) cases: 10 (35.7 %) cases of VH; 13 (46.4 %) cases of AH; 3 (10.7 %) cases of LSH; 1 (3.6 %) case of LAVH; and 1 (3.6 %) case of TLH. The intraoperative complications appeared to be more frequently with heavier uterine weight showing a significant statically correlation ( P < 0,001). Major postoperative complications occurred in 17 of 953 (1.8 %) cases. Minor postoperative complications were recorded in 56 of 953 (5.9 %) hysterectomies. Operation duration, hospital stay and hemoglobin decline correlated significantly with preoperative score ( P < 0.001). Conclusion: The suggested preoperative score is apparently successful in screening out the high-risk patients, despite the low incidence of intra and postoperative complications. The usefulness of the preoperative scoring system is worthy of further development and evaluation. The AH was favored as the 'fallback option' with high preoperative score. [ABSTRACT FROM AUTHOR]

Background: The purpose of this single-center study was to determine the practicability of the intra-operative use of one-step nucleic acid amplification (OSNA) as the only method for detection of SLN. The OSNA system has been well described and is supposed to be as accurate as conventional histology. Methods: Three hundred and thirty SLNs from 143 breast cancer patients were analyzed in an intra-operative setting. The CK19-copy number was determined by OSNA and divided into 3 results ('−' no metastasis; '+' micrometastasis; '++' marcometastasis). If OSNA gave a positive result, an axillary lymph node dissection was carried out during the same session. The central 1-mm slice of each node was obtained for permanent histology. Additionally, the results were correlated to clinicopathological factors, and the time for the intra-operative use was evaluated. Results: Thirty-nine of the 143 patients were OSNA positive, 22 with macrometastatic and 17 with micrometastatic spread. The mean time for the OSNA run with one SLN was 34.4 min. We could show a correlation between the tumor size and OSNA positivity as well as between the numbers of OSNA positive SLNs with the tumor load of associated non-SLNs. Furthermore, we found that a cutoff CK19 copy number of 7,900/μL indicates a positive non-SLN result with the highest sensitivity (91 %) and specificity (61 %). Conclusion: We found OSNA to be very helpful for the intra-operative determination of the tumor load of a SLN as a basis for decision-making concerning further surgical axillary intervention. OSNA allows precise differentiation of micro- from macrometastasis, and the CK19 copy number predicts the probability of tumor load in other axillary lymph nodes and might help to find adequate adjuvant treatment options. This objective method is well suitable for everyday use and may reduce the pathologic workload and the risk of secondary operative interventions with all associated costs and stress for the patients. [ABSTRACT FROM AUTHOR]

The study aimed to evaluate the effectiveness and safety of laparoscopic management of adnexal torsion. Early minimal invasive surgical management of adnexal torsion with the main emphasis on an organ-preserving procedure can safely be recommended. Although the incidence of adnexal torsions has increased, the morbidity rate has declined due to safer diagnostics and operative strategies. This is a retrospective case-control study (Canadian Task Force classification II-3) of 33 cases of adnexal torsion over an 11-year period (December 1999-September 2010) in a gynecologic endoscopy unit of a university hospital. Interventions include early diagnostic laparoscopy and utmost protection of the surrounding tissue. Thirty-three cases of laparoscopically managed adnexal torsions were analyzed. Fifty-two percent had conservative organ-sparing procedures, while 48 % underwent resection of ovary, tube, or both. The mean operating time was 69.2 min. There were no complications or conversions to laparotomy. The most common predisposing factor was an adnexal mass with symptoms of pain. Torsion on the right tube is more common than on the left. Laparoscopic surgery is an effective, safe, and feasible method in the diagnosis and treatment of adnexal torsion. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to assess the morbidity and mortality of patients undergoing surgery for infIammatory bowel disease (IBD) with special focus of the predictive value of the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) scoring system for preoperative risk adjustment of postoperative morbidity. Methods: The operative notes and hospital files of 191 patients with IBD were analyzed. The POSSUM scoring system was used to predict morbidity rates after surgery. The physiological sub-score of the POSSUM score was analyzed with regard to its ability to predict postoperative complications. Results: The overall complication rate was 27.7%, and the mortality was 0.5%. The morbidity rate predicted by POSSUM was 28.4% and the mortality rate 7.2%. The mean POSSUM-phys sub-score in patients without the major complications (anastomotic lekages, peritonitis, bleeding) was significant lower compared to patients with at least one of these complications (14.7 vs. 18.6; p < 0.001). Regarding the major complications separately, there were significant differences in the POSSUM-phys scores in patients developing a sepsis (14.1 vs. 23.4; p < 0.001) and/or a peritonitis (14.8 vs. 19.2; p = 0.05), whereas patients developing an anastomotic leakage/suture dehiscence or a postoperative bleeding did not differ significantly. Conclusion: POSSUM was an accurate predictor of morbidity in IBD patients and overpredicted mortality. The POSSUM-phys score is a promising instrument for identifying patients at increased risk of developing major postoperative complications after surgery for IBD. [ABSTRACT FROM AUTHOR]