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   Table of Contents - Current issue
Coverpage
April-June 2019
Volume 8 | Issue 2
Page Nos. 51-90

Online since Monday, April 29, 2019

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EDITORIAL  

The role of laparoscopy and the value of peritoneal carcinomatosis index in patients with intra-abdominal malignancies who are scheduled to laparotomy p. 51
Peng-Hui Wang
DOI:10.4103/GMIT.GMIT_93_18  
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ORIGINAL ARTICLES Top

Surgical and oncological outcome of total laparoscopic radical hysterectomy versus radical abdominal hysterectomy in early cervical cancer in Singapore p. 53
Timothy Yong Kuei Lim, Krystal Koh Miao Lin, Wai Loong Wong, Ieera Madan Aggarwal, Philip Kwai Lam Yam
DOI:10.4103/GMIT.GMIT_43_18  
Introduction: The Wertheim's radical abdominal hysterectomy (RAH) has been the traditional surgical approach for operable Stage IB cervical cancer in Singapore whereas total laparoscopic radical hysterectomy (TLRH) was introduced only in 2009. In this study, we aimed to compare the long-term surgical outcome between the two routes of surgery in our center. Methods: This is a prospective study performed in a single large tertiary institution in Singapore. Inclusion criteria included surgically fit patients with early cervical cancer and no radiological evidence of regional or distant metastases. Results: From November 2009 to December 2014, 51 TLRHs and 85 RAHs were performed. Median blood loss in the TLRH group was significantly lower than in the RAH group (300 vs. 500 mL; P = 0.002) as was median hospital stay (5 vs. 6 days; P = 0.001). Operative time was significantly higher in the TLRH group (262 vs. 228 min; P < 0.001). There was no significant difference in bladder recovery. Intraoperative complications were encountered in 2 (3.9%) TLRH patients and 1 (1.2%) RAH patient. Postoperative complications occurred in 3 (5.9%) TLRH patients and 8 (9.4%) RAH patients. With a median follow-up of 117 (range 1.6–314.6) weeks in the TLRH group and 143.3 (range 0.4–304.7) weeks in the RAH group, 9 (17.6%) TLRH patients and 7 (8.2%) RAH patients had recurrence. There was no significant difference in the overall 3-year survival between the TLRH group and the RAH group for tumor size ≤2 cm (100.0% vs. 97.0%; P = 0.37). However, there was a trend toward lower survival for the TLRH group for tumor size >2 cm (61.9% vs. 85.4%; P = 0.06). Conclusion: The results of our study suggest that with appropriate patient selection, TLRH can be a safe and effective procedure for the management of early cervical cancer in Singapore, especially in women with small tumors ≤2 cm but should be used with caution in women with larger tumors.
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Salivary human chorionic gonadotropin as a novel biomarker for early detection of pregnancy: A pilot study p. 59
Madhura Mahajan, Uzma Iqbal Belgaumi, Rajendra Baad, Nupura Vibhute, Vidya Kadashetti, Sushma Bommanavar, Wasim Kamate
DOI:10.4103/GMIT.GMIT_47_18  
Context: The role of saliva in detection of pregnancy has not received the due importance it deserves. Aims: The present paper aims at determining the role of saliva in detection of pregnancy using home-based pregnancy detection kits to provide an alternative biofluid that is more user friendly, acceptable, noninvasive, rapid, and easy for home use. Settings and Design: The study was conducted among 35 women visiting a gynecology clinic for confirmation of pregnancy, who gave a history of a missed menstrual cycle not more than 4 weeks. Subjects and Methods: A home-based pregnancy detection kit meant for urinary human chorionic gonadotropin (hCG) detection with 20 mIU specification was used in the study for estimation of salivary hCG. Routine test that was prescribed to the patient such as laboratory-based urine hCG and/or ultrasound examination was used for confirmation of pregnancy status and correlation with the saliva-based result. Results: A positive test was obtained in 74% participants, with a dark band in 43% participants and a light band in 31% participants. A negative result was noted in 26% participants. We observed that salivary hCG estimation showed a 77% accuracy and 23% false-negative results. Conclusions: An astounding 74% of participants showed a positive result with an existing pregnancy kit which indicates a strong plausibility of using salivary hCG as a biomarker for detection of pregnancy. With the findings obtained from our study, we could positively affirm that salivary hCG can be used as a potential, user friendly, and more acceptable biomarker for early detection of pregnancy.
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The Use of ulipristal acetate (Esmya) prior to laparoscopic myomectomy: Help or hindrance? p. 62
Rebecca Mallick, Sam Oxley, Funlayo Odejinmi
DOI:10.4103/GMIT.GMIT_79_18  
Introduction: The aim of this study was to assess the operative effects, both positive and negative, of pretreatment with ulipristal acetate (UPA) on laparoscopic myomectomy. Materials and Methods: We conducted a retrospective analysis of prospectively collected data from patients who underwent a laparoscopic myomectomy over a 2-year period. Results: A total of 62 patients were included, of which 10 received a 3-month preoperative course of UPA, and 52 patients received no pretreatment. There was no statistically significant difference between the two groups (no pretreatment vs. UPA pretreatment) with regard to blood loss (214.4 [±214.96] vs. 160 [±51.64], P = 0.432), operating time (111.64 [±41.8] vs. 117.5 [±50.4], P = 0.694), and duration of inpatient stay (1.27 [±0.56] vs. 1.11 [±0.33], P = 0.419). There were no complications in either group. In 100% of cases with UPA pretreatment, a distortion of the fibroid capsule with a more technically challenging dissection was noted, compared to 0% in the no pretreatment group. This anatomical distortion may result in more cases of incomplete resection and a potentially higher risk of recurrence. Conclusion: We conclude that UPA confers no operative benefits and should be used with caution in the presurgical treatment of fibroids. The use of UPA may indeed result in a more technically difficult myomectomy with distorted cleavage planes and carry a potential risk of incomplete resection.
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The comparison of outcomes between the “skeleton uterus technique” and conventional techniques in laparoscopic hysterectomies p. 67
Adnan Orhan, Isil Kasapoglu, Gokhan Ocakoglu, Oguzhan Yuruk, Gurkan Uncu, Kemal Ozerkan
DOI:10.4103/GMIT.GMIT_125_18  
Aim: The aim of this study is to compare demographic characteristics, operative data, and complication rates of women who underwent total laparoscopic hysterectomy by the skeleton uterus technique (Skeleton-TLH) with those of women who underwent TLH by the standard technique (Standard-TLH) in a university teaching and research hospital. Materials and Methods: This retrospective study included 932 laparoscopic hysterectomies in a university teaching and research hospital between January 1, 2013 and December 31, 2017. Clinical characteristics, operative outcomes, and complications were recorded and compared for the two techniques. Results: In total, 932 laparoscopic hysterectomies were performed, 454 by Skeleton-TLH and 478 by Standard-TLH. The general demographic characteristics of the patients were similar; only gravida and parity were statistically significantly different between the groups (P < 0.001). Based on the primary outcomes (the operative data), total anesthesia time and main operation time were similar in the two groups. Estimated blood loss was statistically significantly lower in the Skeleton-TLH group than in the Standard-TLH group. Hospital stay was longer for the Skeleton-TLH group, and specimen weight was heavier. The secondary outcome was the complication rate. There were no differences between the Skeleton-TLH and Standard-TLH groups in the rates of all minor and major complications. Conclusion: TLH with the skeleton uterus technique is feasible and safe, especially for advanced pelvic surgeons. This technique not only provides retroperitoneal access to the pelvic spaces and good anatomical visibility; but it also delivers a safer laparoscopic hysterectomy by clamping the uterine arteries and monitoring the ureter throughout the operation.
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CASE REPORTS Top

Isolated incisional recurrence in a patient with early-stage endometrial cancer: A case report and review of the literature p. 73
Takashi Hirayama, Soshi Kusunoki, Kazunari Fujino, Yasuhisa Terao, Atsuo Itakura
DOI:10.4103/GMIT.GMIT_81_18  
Isolated incisional recurrence in a patient with early-stage endometrioid carcinoma is extremely rare. The mechanism of this recurrence also remains unclear. We describe a case of an isolated incisional recurrence of endometrioid carcinoma from the uterine corpus 4 years after the primary surgery. We review the previous literature and discuss the possible mechanism of isolated incisional recurrence. A 56-year-old woman diagnosed with the International Federation of Gynecology and Obstetrics Stage IA and Grade 2 endometrioid carcinoma in the uterine corpus showed an isolated cystic mass in the abdominal wall 4 years after the primary surgery. She underwent resection of the abdominal tumor, and the pathological findings showed endometrioid carcinoma, which was the same as the primary tumor. She received chemotherapy and remained disease free 8 months after chemotherapy. Long-term follow-up is required to detect recurrence, even in patients with early-stage uterine corpus carcinoma.
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Successful surgical treatment for congenital vaginal agenesis accompanied by functional uterus: A report of two cases p. 76
Chihiro Minami, Ryosuke Tsunematsu, Kana Hiasa, Katsuko Egashira, Kiyoko Kato
DOI:10.4103/GMIT.GMIT_124_18  
We present two cases of congenital vaginal agenesis with functional uterine corpus, manifesting with periodic lower abdominal pain and hematometra in adolescence. Both patients were successfully treated with the creation of neovagina and neocanal structures to discharge menstrual blood; this may also facilitate the preservation of fertility. Both cases were characterized by degrees of congenital vaginal agenesis, whether short or completely absent, with no communication between the uterine cavity and external genitalia, as confirmed by physical examination and imaging. We surgically reconstructed a neovagina with the modified McIndoe's procedure, using an artificial skin graft, and canalized to the caudal portion of the uterine cavity. Although redilatation of the neocanal was required, no patient suffered severe infection in postoperative course and both now exhibit regular menstruation. Although hysterectomy has classically been the preferred treatment for such cases, recent technical progression enables treatment of such diseases with conservative and minimally invasive surgery, in a safe manner.
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Immunotherapy with subcutaneous injection of immunomodulatory agent (OK-432) elicits durable response in locally advanced or relapsed cervical cancer p. 80
Quenny Michelle Dyan A. Alas, Cheng Tao Lin
DOI:10.4103/GMIT.GMIT_1_19  
Immunotherapy (IT) has been studied as a new and alternative treatment option for locally advanced, persistent, recurrent, or relapsed cervical cancer in an effort to extend the life and possibly cure patients with advanced stage disease. Targeted immune checkpoint inhibitors augment anticancer immunity and prolong patient's life span without immune-related adverse events (irAEs). Here, we present a case of a 56-year-old woman, gravida 2 para 0, diagnosed with squamous cell carcinoma of the cervix stage IVB who received IT coupled with subcutaneous injection of immunomodulatory agent (OK-432) during her standard treatment of concurrent chemoradiation therapy (CCRT) and as a maintenance therapy after CCRT due to relapsed cervical cancer. This form of treatment strategy showed good response as reflected by a decrease in tumor biomarker with no notable serious irAEs.
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Intrauterine contraceptive device perforating the cecum, a pregnancy complication? p. 83
Luay Ibrahim Abu Atileh, Mohammad Anas Mourad, Dania Haj-Yasin, Laith Shlash, Laith Zaid Kaylani, Nardin Fadila
DOI:10.4103/GMIT.GMIT_109_18  
Intrauterine contraceptive device (IUCD) is a widely used method of contraception worldwide. Displacement of the IUCD extrauterine, by perforating the uterus and migration, is a serious complication following its insertion. We reported an extremely rare case of a 24-year-old female patient found to have a copper T 380A IUCD displaced from its normal site to be embedded into the cecum, suggested to have occurred during pregnancy, and being successfully removed laparoscopically.
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CLINICAL IMAGE Top

Removal of a retroperitoneal foreign body by laparoscopic surgery p. 86
Saeki Shinichiro, Yu Wakimoto, Hidetake Kamei, Atsushi Fukui, Hiroaki Shibahara
DOI:10.4103/GMIT.GMIT_84_18  
Migration of intrauterine devices (IUDs) into the abdominal cavity is rare. In this report, we describe a patient in whom a levonorgestrel intrauterine system (LNG-IUS) device was initially misplaced outside of the uterus, likely due to stenosis of the cervix following a conization procedure for carcinoma in situ. The patient presented with persistent abdominal pain and vaginal bleeding. The LNG-IUS was not visible on physical examination and ultrasound imaging, requiring intraoperative abdominal radiography and postoperative computed tomography for localization. Once localized, we proceeded with the removal of the foreign body in the retroperitoneal space by laparoscopy. Misplacement of an IUD such as LNG-IUS outside of the uterus after a conization procedure should be suspected in women with persisting symptoms, and this possibility should be diligently assessed.
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LETTER TO THE EDITOR Top

Malignant ovarian lesion complicated by a rare entero-ovarian fistula p. 89
Reddy Ravikanth, Kanagasabai Kamalasekar
DOI:10.4103/GMIT.GMIT_127_18  
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