Intraperitoneal Triamcinolone Reduces Postoperative Adhesions, Possibly through Alteration of Mitochondrial Function

Adhesions frequently occur postoperatively, causing morbidity. In this noninterventional observational cohort study, we enrolled patients who presented for repeat abdominal surgery, after a history of previous abdominal myomectomy, from March 1998 to June 20210 at St. Vincent’s Catholic Medical Centers. The primary outcome of this pilot study was to compare adhesion rates, extent, and severity in patients who were treated with intraperitoneal triamcinolone acetonide during the initial abdominal myomectomy (n = 31) with those who did not receive any antiadhesion interventions (n = 21), as documented on retrospective chart review. Adhesions were blindly scored using a standard scoring system. About 32% of patients were found to have adhesions in the triamcinolone group compared to 71% in the untreated group (p < 0.01). Compared to controls, adhesions were significantly less in number (0.71 vs. 2.09, p < 0.005), severity (0.54 vs. 1.38, p < 0.004), and extent (0.45 vs. 1.28, p < 0.003). To understand the molecular mechanisms, human fibroblasts were incubated in hypoxic conditions and treated with triamcinolone or vehicle. In vitro studies showed that triamcinolone directly prevents the surge of reactive oxygen species triggered by 2% hypoxia and prevents the increase in TGF-β1 that leads to the irreversible conversion of fibroblasts to an adhesion phenotype. Triamcinolone prevents the increase in reactive oxygen species through alterations in mitochondrial function that are HIF-1α-independent. Controlling mitochondrial function may thus allow for adhesion-free surgery and reduced postoperative complications.

Reoperation rates for recurrence of fibroids after abdominal myomectomy in women with large uterus

Background The population of women undergoing abdominal myomectomy for symptomatic large fibroid uterus is unique. We seek to characterize the timing, risk factors as well as the presenting symptoms which led patients to undergo repeat surgery in this patient population. Methods and findings We followed 592 patients who underwent an abdominal myomectomy from March 1998 to June 2010 at St. Vincent’s Catholic Medical Center and presented later during the study period with a recurrence of symptoms attributable to a reemergence of fibroids and who chose to undergo repeat surgical management. Twelve percent of patients exhibited symptoms of fibroid uterus which led to reoperation within the study period. The mean age at repeat surgery was 44.1 ± 0.6 years old (n = 69) and the mean time between operations was 7.9 ± 0.3 years. Presentation was variable but included bleeding, pain and infertility. Patients presented for surgery with a significantly smaller sized uterus than at their initial surgery. Timing between surgeries correlated with age at initial surgery and uterine size but race, number of fibroids, aggregate weight of fibroids removed, operative time or blood loss at the initial surgery did not correlate. Data is suggestive that intraperitoneal triamcinolone may reduce reoperation rates but not timing of recurrence. Conclusion These results may help in counseling patients, particularly younger women, on the risks of fibroid recurrence necessitating repeat surgery. Further research is necessary to assess if triamcinolone can alter fibroid reurrence in patients who undergo uterus sparing procedures.

Uterine submucosal leiomyomas: modern diagnosis and miniinvasive surgery

Uterine leiomyomatosis is one of the most common benign pelvic tumors diagnosed in women aged 25-44 years. Clinically, it is manifested by vaginal bleeding, pelvic pain, infertility, digestive and urinary symptoms. The diagnosis of uterine fibroids requires careful clinical and paraclinical evaluation. Based on these data, the therapeutic decision is conducted in most cases. The treatment of uterine leiomyomatosis involves several procedures, such as: total abdominal hystectomy, total vaginal hystectomy, abdominal myomectomy, vaginal, laparoscopic or hysteroscopic myomectomy. Hysteroscopic myomectomy is currently the preferred procedure for submucosal fibroids. It has multiple advantages: shorter recovery time, reduced pain related to movements, shorter duration procedure and fewer risks. The procedure has few contraindications. The most common complication is recurrence. The treatment of choice for prolapsed pedunculated submucous leiomyoma is vaginal myomectomy. As described, the procedure has multiple advantages and generally has a low recurrence rate.

REPRODUCTIVE OUTCOMES AFTER ABDOMINAL MYOMECTOMY

Objective: To determine the frequency of reproductive outcomes after abdominal myomectomy in infertile women. Study Design: Case series. Place and Duration of Study: at Combined Military Hospital, Multan Pakistan, from Sep 2015 to Feb 2017. Methodology: This study included 60 women who underwent myomectomy to retain their capabilities of reproduction. Inclusion criteria were infertile women with uterine fibroids. Routine investigation was done to all patients like ultrasound and hysterosalpingogram before and after the procedure. The procedure of abdominal myomectomy was done under general anesthesia. All fibroids were enucleated and large blood vessels were tied. Vicryl no.1 was used to close the uterine defect. All patients were followed up for 3, 6 and 12 months interval and data was collected for conception, spontaneous conception, and conception with assisted reproductive technique, live birth and miscarriage. Results: In this study mean age was 27.33 ± 4.03 years, mean number of fibroid was 1.366 ± 0.48 and mean size of fibroid was 7.06 ± 1.64 cm. Twenty eight (46.7%) women had conceived after myomectomy, in which 92.9% had spontaneous conception and 7.1% by assisted reproductive technique. Conclusion: Abdominal myomectomy should be the standard treatment of infertile women with uterine fibroids if no other underline cause of infertility. Moreover, this study results also showed that younger patients might be benefited more in term of reproductive outcomes after abdominal myomectomy.

Efficacy of Preoperative Misoprostal in Reducing Hemorrhage during Abdominal Myomectomy

Objective: The aim of this study is to determine the efficacy of preoperative misoprostal in reducing hemorrhage during abdominal myomectomy. Study Design: Prospective comparative randomized double blinded Place and Duration: Conducted at DHQ Zanana hospital Dera Ismail Khan for one year duration from January 2019 to December 2019. Methods: Total 100 patients underwent abdominal myomectomy were presented in this study. Patients were aged between 18-45 years of age. Patients’ detailed demographics including age, body mass index and parity were recorded after taking informed written consent. Patients were categorized equally into two groups, I and II. Group I had 50 patients and received single dose 400 micrograms of misoprostol transrectally one hour preoperatively and group II had 50 patients and received 2-tablets of placebo preoperatively. Outcomes intraoperative blood loss, blood transfusion, hysterectomy and complications among both groups were assessed. Complete data was analyzed by SPSS 23.0 version. Results: Mean age of the patients was 32.16±9.44 with mean BMI 26.07±10.44 kg/m2. There were no significantly difference among age and body mass among both groups. 60 Patients had 0 parity, 30 patients had parity 1 and the rest were had parity 2. Mean pre-operative hemoglobin in group I was 13.64±8.55 and post-operative was 9.88±8.55 and in group II mean pre-operative hemoglobin was 13.55±8.55 and post-operative was 9.12±5.55. Mean intraoperative blood loss in group I was 388.17±37.18 ml and in group II was 501.16±17.64 ml. Post-operatively blood transfusion in group I was among 2(4%) cases and 3 (6%) in group II. Mean hospital stay in group II was greater as compared to group I. Nausea, vomiting and shivering were the complications found in this study. Conclusion: We concluded in this study that the use ofmisoprostol preoperatively during abdominal myomectomy was effective safe and useful in reduction of intraoperative blood loss and post-operatively blood transfusion among patients. Keywords: Abdominal myomectomy, Misoprostol, Placebo, Intraoperative, Blood loss

Reducing the risk of bleeding after myomectomy: is preemptive embolization a valuable tool?

Purpose Abdominal myomectomy can be a challenging procedure, with elevated intraoperative blood loss and post-operative complications such as the need for blood transfusion and hemostasis with sometimes hysterectomy. Previous studies suggested that preemptive uterine artery embolization (PUAE) might reduce intraoperative blood loss. Materials and methods We reviewed all cases of abdominal myomectomy in our institution between January 2016 and June 2018. Out of 119 cases, 16 patients had PUAE and 103 did not. The objective of our study was to determine whereas PUAE reduced blood loss and post-operative complication rate. Results In our study, there was no difference between the two groups in regard to average blood loss (128 vs 192 mL, OR 1,00 [0.99;1,01], p = 0,73), difference between pre- and post-operative hemoglobin level (− 1,15 g/dL vs − 1,32 g/dL, OR 0,91 [0.47;1,73], p = 0,79), and post-operative complications (need for transfusion, surgical revision, post-operative embolization, hysterectomy). Conclusion Our findings could not conclude that PUAE is effective in reducing intraoperative blood loss during abdominal myomectomy, but it should still be considered an option for patients with large or multiple myomas, with a specific situation or previously operated, who wish to preserve their uterus.