Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411012EnglishN2018June22HealthcareComparison between Laparoscopic High Uterosacralligament Suspension and Laparoscopic Sacrocolpopexy: A Retrospective Study
English0107Jacqueline Miyuna BakisololoEnglish Wang HualiEnglish Audrey Muntanda BazolanaEnglish Deng YanjieEnglish Roger Mbungu MwimbaEnglish Yanga KidiameneEnglish Lokomba BolambaEnglish Mboloko EsimoEnglish Tesfaldet HabtemariamEnglish Ding Xiao DanEnglishBackground: Pelvic organ prolapse is a latent disease that may take origin after injury of the connective tissue. This investigation aims to compare the surgery outcome of the Laparoscopic High Uterosacral ligament suspension (LHULS) and the Laparoscopic Sacrocolpopexy (LSC).
Materials and Methods: This is a retrospective study. Fifty-three participants with pelvic organ prolapse stage ≥II referring to pelvic organ prolapse quantification (POP-Q) system were desirable in this study. Thirty participants underwent LSC, twentythree others experienced the LHULS surgery. The surgery outcomeand patient’s satisfaction were assessed by the POP-Q
system, and the pelvic floor questionnaires PFDI-20, PFIQ-7, PISQ-12, respectively. Whitney-Test was utilized to analyze the pre-and post-operative results between groups, while the Wilcoxon signed rank test was used to compare the pre-and postoperative
outcomes.
Result: The POP-Q score improved significantly for both groups postoperatively. LSC was superior to LHULS in the anterior compartment, the postoperative mean for Ba was (2.54 ±0.56 Vs -2.39± 1.47). The LSC was superior to The LHULS in the posterior compartment as well; Bp(2.50± 1.96 Vs-2.08±1.3, PEnglishLaparoscopic, Sacrocolpopexy, Uterosacral ligament suspension, Effectiveness
Introduction
Pelvic organ prolapse is a latent disease that may take origin after injury or abnormalities of the connective tissue, Levator ani muscles, nerve, and vessels. Over time, these disturbances will increase and become obvious later in life [1- 4]. The demand for prolapse treatment is increasing as longevity increases. After menopause, the probability to suffer from prolapse is estimated to be as higher as 50 percent [5].
The challenge of surgeons is to care and cure the affected population with different kinds of techniques, provided that those techniques proof their effectiveness. [6]
Abdominal Sacral colpopexy (ASC) has a reputation for being the cornerstone in repairing the vault prolapse [7], furthermore, it has an important place in restoring the multi-compartment pelvic organs herniation [7], and the recurrence protruded organs. The laparoscopic approach has highlighted the increasing benefit of this procedure by magnification and minimal invasion [7]. Studies conducted to compare the laparotomic and the laparoscopic sacrocolpopexy(LSC) concluded that the surgery outcomes were similar with some limitation for both sides. The laparotomic surgery’s and hospitalization time was higher than the laparoscopic approach [7, 8]. The Laparoscopic technique, however, minimizes these issues. Moreover, the manipulation of the gut is less [7]. Nevertheless, the LSC requires an experience [8].
On the other hand, the laparoscopic high uterosacral ligament suspension (LHULS) has shown good anatomic outcome for vault prolapse [9-12]. Interestingly, this procedure does not require any graft, therefore, the concerns about the graft-related complications are dispelled [11]. Furthermore, it has an advantage of better view by magnification and being less aggressive [9].
Materials and Methods
This is a retrospective study. Fifty-three participants with pelvic organ prolapse stage ≥II referring to pelvic organ prolapse quantification system were desirable in this study between April 2014 and May 2017.Thirty participants underwent LSC and twenty-three others experienced LHULS at Dalian Gynecology and Obstetrical (Maternal and child health care) Hospital. The womenwithtroublesome prolapse, and with pelvic prolapse stage equal or greater II were included in this investigation. The smoking women and patients who were not acandidatefor laparoscopic surgery to treat prolapse were excluded. The LSC surgery was done by two gynecologists, one of the two gynecologists also performed the LHULS surgery. The analysis was done for afollow up of 12months.
Ethical approval
The Ethics committee of Gynecology and Obstetrical (Maternal and child health care) Hospital and Dalian Medical University approved the study.
Patients evaluation
All participants had a complete clinical examination before surgery. The surgery outcome was evaluated by the pelvic prolapse quantification (POP-Q) system, the satisfaction of patients was assessed by the pelvic floor questionnaires including the Pelvic floor distress inventory-20, pelvic floor impact questionnaire-7 and pelvic prolapse incontinence sexual questionnaire-12, respectively PFDI-20, PFIQ-7, PISQ-12. We assessed the intraoperativedetails and surgical complications.
Operation procedure
1. Laparoscopic Sacral Colpopexy
The general anesthesia was used. The patient was placed in the recumbent position, legs flexed and sustained by stirrups. Theskin disinfection, the sterile draping, and urinary catheterization were then performed.Firstly, we placed four trocars on the abdomen. The initial 10mm at the umbilicus, twolateral 5mm trocars at one-third of the umbilical-spinous line at either side, and the last trocar was inserted 4cm ascendant from the left lateral 5mm trocar. A hysterectomy was done when required.The vesicovaginal and the rectovaginal pouchwere opened at the lowest part of the prolapse. Then, the promontory dissection was completed by the incision of the paravertebral peritoneum and the retroperitoneum fat, after identification of the L5-S1, the right ureter, and iliac vein. Hence, the anterior longitudinal ligament was visible. Furthermore, the incision of the peritoneum at the sacral promontory was extended medially. Therefore, the Y-shape mesh was used (monofilament, macroporous polypropylene mesh GYNECARE of U.S.A. and Budd Company of Germany). With two columns of six interrupted sutures,we then sutured the arms of the mesh at the anterior and the posterior compartment. Finally, we attached the mesh on the anterior sacral longitudinal ligament with non-absorbable suture. The peritoneum closure was achieved by a running suture. The patientswere recommended the useof vaginal estrogen cream at least for six months after surgery. And they could start sexual life after three months and encouraged to use
2. Laparoscopic High Uterosacral ligament suspension
Under general anesthesia, we disinfected and covered with sterile clothes the patient which liedin the lithotomy position. We began to insert four trocars in the abdomen, one on the umbilicus of 10mm, two laterals 5mm each and another midway between the umbilicus and the external iliac spine. Then, we identified the uterosacral ligaments and ipsilateral ureter. We made an incision in the peritoneum between the ligament and the ureter to avoid ureter damage. A non-absorbable suture was placed in running mode through the proximal, middle and distal of either uterosacral Ligament. The uterus sacral ligament was folded and shortened. The shortened uterosacral ligament was sutured at the vaginal part of the cervix (if the uterus is preserved) or to the vaginal cuff (when a hysterectomy has been performed).
The patients were prescribed a vaginal estrogen cream after surgery for a duration of six months and more and attempt sexuality three months later.
Follow up process
After surgery, the patients were reviewed. The surgery outcome and the patient’s satisfaction were assessed as well. We checked for any bulge, mesh exposure, and urine leakage by the cough test. The subjective outcome was assessed by the valid quality of life questionnaire short form PFDI-20, PFIQ-7, PISQ-12.
Statistics Analysis
The data are described as a mean ± standard deviation, median (range), rate as fitting. The Mann Whitney-Test was utilized to analyze the postoperative results between groups, while the Wilcoxon signed rank test was used to compare the pre-and post-operative outcomes Then, we used the chi-square (Pearson chi-square, continuity correlation, Fisher exact accordingly) for categorical data. We used the IBM SPSS statistics version 21, the p< 0.05 was considered as statistically significant.
Result
The baseline characteristics of the patients are shown in table 1. The LSC group have a high rate of menopaused women than the LHULS group (P=0.01). There was no difference in age, BMI, and other risk factors.
Table 2 demonstrates the POP-Q result showing that there was a statically significant amelioration in POP-Q scores, except for the point Ba in LHULS group and for TVL and PB for both LHULS and LSC groups; when comparing the preoperative to postoperative outcomes. The two groups were different in all compartments before surgery, except for Ap, GH, TVL. PB. The postoperative POP-Q measurement demonstrated a significant difference in mean Aa, which was -2,40±1.3 versus -2.86±0.46 respectively for LSC and LHULS(P=0.04), while the mean postoperative for the point Bpimproved better in LSC compared to LHULS group (-2.50± 1.96 versus -2.08±1.3, P=0.008).The genital hiatus(GH) was greater for LSC group (3.75 ± 1.13 versus 2.78 ± 1.38, P= 0.004).Similarly, the point Ba improved more in LSC group (-2.54 ±0.56 Vs-2.39± 1.47); as shown in table 2. We defined the surgery success as POP-Q Aa, Ba, C, Ap, Bp less than -1. There was no difference in success rate between groups. In all sites, we obtained a success rate of 87% and 87% for both LHULS and LSC respectively. Moreover, no difference was detected in relapse rate (13.33% versus13.04%) for LSC and LHUSL respectively.
The patients' satisfaction assessment is seen in Table 3. The PFDI-20 improved significantly for both groups, except for the CRADI-8 domain. The PFIQ-7 did not improve significantly in all domains for LSC group,while in the LHULS group, there was an improvement for the PFIQ-7 questionnaire in total and for the UIQ-7 domain. For both groups, there was no difference after surgery in CRAIQ-7domain.
The operation’s details and complications are shown in Table 4. LSC held an extended surgical time than LHULS (177[50-350] versus 115 [70-190], PEnglishhttp://ijcrr.com/abstract.php?article_id=2498http://ijcrr.com/article_html.php?did=2498[1]. Patrick Dällenbach to mesh or not mesh: a review of pelvic organ reconstructive surgery, International Journal of Women’s health. 2015; 7: 331-343. doi.org/10.2147/IJWH.S71236
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411012EnglishN2018June22HealthcareA Case Report of Cytomegalovirus Esophagitis in an Immune-competent Patient
English0811Dosieah PoojaEnglish Jagessar SabreenEnglish Zhang ZhenyuEnglishCytomegalovirus (CMV) esophagitis usually occurs in immunocompromised individuals. Cases of Cytomegalovirus esophagitis in immunocompetent patients have not been reported yet in China. This report is mainly based on a case study and the relevant literature review to summarize the clinical manifestations, endoscopic characteristics, diagnosis and treatment of cytomegalovirus
esophagitis in immunocompetent patients.
EnglishCytomegalovirus, Esophagitis, Immune competent, Literature reviewCytomegalovirus (CMV) can cause various kinds of diseases in the human body, such as encephalitis, retinitis, hepatitis, pneumonia and so on [1,2,3]. Cytomegalovirus gastroenteritis
is rare, but esophagitis is the second most common gastrointestinal manifestation of cytomegalovirus (CMV) infection after colitis [4]. It usually occurs in patients with immunodeficiency, such as HIV infection, history of organ transplantation, long-term history of renal dialysis, and long-term use of immunosuppressant [5].
There is currently growing proof of CMV infection in immunocompetent patients [6,7,8]. Here, we present a case of CMV esophagitis in an immunocompetent patient, who presented with severe progressive chest pain and dysphagia. The patient was successfully treated with ganciclovir. This positive outcome has been added to an updated review of the literature relating to CMV esophagitis in immunocompetent hosts.
Case Presentation
A 71-year-old male patient was admitted to the hospital on April 15, 2016 following 20 days of progressive chest pain and dysphagia. After eating, he constantly had difficulty swallowing, but had no symptoms like nausea and vomiting, melena, cough and sputum, chills or fever.
Upon referral, the patient underwent esophagogastroduodenoscopy (EGD), shown in Figure 1, which revealed a rough esophageal mucosa, scattered multiple ulcers were visible about 30-36cm from the incisor teeth, covered with a thin white coating, surrounded by slightly hyperemic peripheral mucous membrane which was altogether diagnosed as multiple esophageal ulcers. The patient had a history of hypertension, cerebral infarction, but no oral antiplatelet drugs. After admission, for acid suppression and mucosal protection, symptomatic and supportive care was given. There was no obvious abnormality in the blood routine examination, urine test, Biochemistry examination, tumor marker, blood transfusion test, anti nuclear antibody, anti neutrophil cytoplasmic antibody, enhanced CT of the chest and abdomen. Other laboratory results showed: Cytomegalovirus IgM antibody (-), cytomegalovirus IgG antibody (+), cytomegalovirus DNA (-), EB virus early antigen IgG (-), EB virus shell antigen IgA (-), EB virus nuclear antigen IgA (-). Colonoscopy results revealed colorectal polyps, which was then treated with EMR (Endoscopic Mucosal Resection). Postoperative pathology results showed tubular adenoma of the sigmoid colon and rectum with glandular low-grade intraepithelial neoplasia. A high-grade intraepithelial neoplasia was found in the focal point. Gastroscopic pathology (Shown in Figure 2) revealed esophageal ulcers and more inflammatory cell infiltration with granulation tissue, scattered macrophages, multiple inflammatory cell infiltration in the middle of squamous epithelium. Immunohistochemistry (shown in Figure 3) revealed HSV-1 (-), CMV (+). After treatment, the patient’s symptoms were slightly improved. On April 22, another gastroscopy was performed. As shown in Fig. 4, 6-8 shallow ulcers were seen at a distance of 30-36 cm from the incisors, and the size varied from 0.4cm to 0.4cm to 0.6x0.6cm. The boundary was well defined and clear. The base was smooth
and the mucosa between the lesions was normal. After the first endoscopic immunohistochemistry, CMV was found positive.
DISCUSSION
The cytomegalovirus (CMV) belongs to the herpes virus family and DNA virus and can be infected through placenta, contact, injection, blood transfusion, or organ transplantation. Once a person has CMV infection, he or she always carries the virus for life. Cytomegalovirus esophagitis usually occurs in immunocompromised patients, such as HIV infection, organ transplantation, long-term use of immunosuppressive patients, etc. The older age of onset may be due to the weakening of immunity of older patients and the decrease of resistance [9], and more basic diseases of the elderly, such as chronic obstructive pulmonary disease, hypertension, diabetes, etc. Some medicines used to treat underlying diseases may damage the digestive tract and are more susceptible to cytomegalovirus infection.
In patients with normal immune function, cytomegalovirus esophagitis mainly presents with chest pain, swallowing pain, hematemesis, and melena, as well as patients with weight loss, difficulty in swallowing, etc. Cytomegalovirus esophagitis in immunocompetent patients and immunodeficient patients showed similar clinical symptoms, which is consistent with previous reports [10]. Endoscopic manifestations of esophageal mucosal erosion, ulcers, erosions and
ulcers often occur in the lower esophagus, but also occur in the upper esophagus. Ulcers are often multiple, and can also be solitary. The borders of ulcers are smooth and the base is
knife-cut or coated with a small amount of white moss.
The key to the diagnosis of cytomegalovirus esophagitis is the discovery of cytomegalovirus inclusion bodies in the nucleus of the biopsy tissue. Since cytomegalovirus often infects fibroblasts and endothelial cells, cytomegalovirus inclusion bodies are easily found on the base of ulcers. Therefore, biopsy specimens should be taken from the base of ulcers, which can increase the detection rate of inclusion bodies [11,12]. There are also opinions that biopsies should be taken from the edge of the ulcer and multinucleated giant cells or nuclear inclusions can be found [13]. Positive cytomegalovirus immunohistochemistry is considered the “gold
standard” for the diagnosis of cytomegalovirus esophagitis [14]. In addition, serological tests, PCR methods for the detection of DNA, serum, or urine culture are important auxiliary diagnostic methods [15].
The treatment of cytomegalovirus esophagitis, the most widely used is the intravenous infusion of ganciclovir, treatment for at least 2-3 weeks [16], for ganciclovir intolerance, can be considered with foscarnet sodium [17]. Antiviral therapy is particularly important for patients with immunodeficiency. In the study done, (shown in table 1) 9 patients with normal immune function and 7 patients were treated with ganciclovir. However, it is worth noting that another 2
patients were cured with supportive treatment alone.
In summary, although cytomegalovirus esophagitis is rare in patients with normal immune function, when esophageal ulcers and diffuse erosions are detected by gastroscopies,
the possibility of cytomegalovirus esophagitis must be considered when the cause of common esophagitis is excluded. Cytomegalovirus related tests should be performed, especially pathological examination. Once diagnosed, antiviral treatment may be considered. However,
whether antiviral treatment must be necessary, further studies are still needed.
CONCLUSION
In conclusion, we have portrayed our perceptions of one immune competent patient with CMV esophagitis and have checked on nine detailed cases. This data demonstrates that CMV esophagitis can cause critical morbidity, even in immune competent patients, and support leading substantial examinations to decide the clinical helpfulness of ganciclovir
treatment.
ACKNOWLEDGEMENT
I would like to extend my gratitude to my professor, Dr. Zhang Zhen Yu and my colleague Dr Tan Lu Xuan for encouraging me and helping me in writing this article.
I am also grateful to all the authors, editors and publishers of all those articles, journals and books from where the literaturefor this article has been reviewed and discussed.
Source of Funding: No funding
Conflict of Interest: No conflict of interest.
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