Management Dilemma of an Infertile Patient with More Than 20 Submucous Fibroids

Background: Submucous fibroids can lead to menorrhgia, infertility, recurrent pregnancy loss, and obstetric complications. The management of multiple submucous fibroids in patients who would like to preserve their reproductive function can be a challenge. The aim of this report is to discuss the management dilemma of a patient who presented with multiple (more than 20) submucous fibroids. Case: The patient was a 33-year-old Caucasian woman who had an initial complaint of menometrorrhagia and secondary infertility, which led to a diagnostic hysteroscopy. Multiple submucosal fibroids were noted; no other etiology for infertility was identified. She subsequently underwent hysteroscopic resection of several fibroids. Postoperative hyterosalpingogram demonstrated intrauterine scarring, unilateral tubal blockage, and several remaining fibroids. She did, however, conceive with intrauterine insemination. Unfortunately, this pregnancy ended in an early spontaneous abortion of twins. After being counseled on her options, including the possibility of needing a surrogate uterus, she elected to have an abdominal resection of the remaining fibroids. During this procedure, several steps were taken to restore the uterine cavity to a normal shape. After allowing her uterus to heal, she achieved pregnancy through in vitro fertilization. At 29 weeks of gestation, she had preterm premature rupture of membranes and, subsequently, had a cesarean section at 34 weeks of gestation. She had a viable 6 pound 1 ounce baby boy. At the time of her cesarean section, only one submucosal fibroid was identified. Conclusion: We present a unique case of multiple sub-mucous fibroids that failed hysteroscopic management and were subsequently treated successfully with hysterotomy, myomectomy, and uterine reconstructive surgery. Based on our experience with this case, we recommend hysterotomy and myomectomy for management of multiple sub-mucous fibroids from the outset. (J GYNECOL SURG 31:274)Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140098/1/gyn.2014.0123.pd

Gestational Sac Aspiration of Heterotopic Ectopic Pregnancy in a Cesarean Section Scar

Background: This article describes a case of heterotopic pregnancy that included a normal twin intrauterine pregnancy and one cesarean section (CS) scar pregnancy diagnosed at 6 weeks of gestation. Ultrasound-guided aspiration of the ectopic gestational sac was performed, and the concurrent twin intrauterine pregnancy (IUP) was preserved successfully. The patient was a 50-year-old woman with secondary infertility. Case: The patient underwent in vitro fertilization and embryo transfer using a donor-egg program to achieve pregnancy with her current partner. At 6-weeks' gestation, she underwent a transvaginal ultrasound scan (US) examination showing a viable twin IUP with a third gestational sac with viable embryo located low within the anterior wall of the uterus. The appearance was consistent with a cesarean scar ectopic pregnancy. This was confirmed on a subsequent US 1 week later. She desired to continue the intrauterine pregnancy. US-guided aspiration of the cesarean scar ectopic pregnancy was attempted. The treatment was successful. Results: The twin pregnancy progressed without further complications. Conclusions: Heterotopic CS ectopic pregnancy can be successfully treated with transvaginal US-guided aspiration. (J GYNECOL SURG 29:317)Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140090/1/gyn.2012.0026.pd

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10 years; 78.2% included were male with a median age of 37 years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

Robotic surgery in the management of benign complex adnexal masses with a frozen pelvis in women desiring to preserve fertility

Background: A “frozen pelvis” is a term often used to describe extensive pelvic adhesions. It is considered as one of the most challenging situations that a gynecologic surgeon can face. It commonly is caused by extensive endometriosis and pelvic inflammatory disease. We present two cases with extensive pelvic adhesive disease with the aim to illustrate the value of robotic assisted laparoscopy in the management of benign complex adnexal masses with severe pelvic adhesive disease in women desiring to preserve the fertility. Case 1: A 27 year old female referred to our clinic for evaluation of a complex left adnexal mass. Trans-vaginal ultrasound scan and an MRI suggested bilateral endometriomas. She was noted to have stage IV endometriosis. Da Vinci robot assisted left salpingo-oophorectomy was performed. Case 2: A 43 year old female presented with recurrent episodes of pelvic inflammatory disease following an unsuccessful in vitro fertilization procedure. A trans-vaginal ultrasound scan showed a complex left adnexal mass. She was noted to have extensive pelvic adhesions secondary to chronic pelvic inflammatory disease. Da Vinci robotic assisted left salpingectomy was performed, while preserving the left ovary. Conclusion: Our experience and review of literature suggest that in hands of an experienced surgeon, the inherent advantages of robotic assisted operative laparoscopy makes it a safe and attractive alternative to conventional operative laparoscopy and laparotomy for managing benign complex adnexal masses with concomitant severe pelvic adhesive disease in women desiring to preserve their fertility

Initial Egyptian ECMO experience

Introduction: Extracorporeal membrane oxygenation (ECMO) is considered a rescue therapy in severe cases of acute cardiac and or respiratory failure. Aim of the work: We describe our initial experience at the first ECMO center in Egypt. Methods: Our adult ECMO program started in January 2014. Since then we supported eleven respiratory failure patients on ECMO indicated according to ELSO guidelines and one case of ECMO CPR. Respiratory failure patients were subjected to VV ECMO when lung injury score (LIS) was above 3 and PaO2/FiO2 <100 on protective lung strategy mechanical ventilation according to ARDS net protocol and or severe hypercapnia with pH < 7.2 with trial of prone positioning in the indicated cases. Percutaneous cannulation was done in all patients using single lumen cannulae, additional cannula was added when needed. Cardiohelp (Maquet, Germany) and Rotaflow (Maquet, Germany) ECMO consoles were used with centrifugal pump. ECMO circuits PLS for Rotaflow and HLS for Cardiohelp were changed when indicated. The ECMO CPR patient was a primary PCI for acute inferior STEMI complicated by left main occlusion, VA ECMO instituted in the cath-lab after 20 min of CPR. Percutaneous (and or surgical) tracheostomy was done after 14 days of mechanical ventilation. Results: A total of twelve patients received ECMO between January 2014 and June 2015. The mean age was 35.9 years. (range 13–65 years), 8 males, with VV ECMO in 10 patients, and VA ECMO in 2 patients. Out of ten patients of VV ECMO, one had H1N1 pneumonia, one had advanced vasculitic lung, four had bacterial pneumonia, two traumatic lung contusions and one with organophosphorus poisoning, and one undiagnosed etiology leading to severe ARDS. Lung injury score range was 3–3.8, PaO2/FiO2 (20–76) mechanical ventilation duration before ECMO 1–14 days, Femoro-jugular cannulation in 7 patients and femoro-femoral in 2 patients and femoro-subclavian in 1 patient; all patients were initially sedated and paralyzed for (2–4 days) and ventilated on pressure controlled ventilation with Pmax of 25 cm H2O and PEEP of 10 cm H2O. In VA ECMO patients were cannulated percutaneously using femoro-femoral approach. One patient showed no neurologic recovery and died after 24 h, the other had CABG on ECMO however the heart didn’t recover and died after 9 days. Heparin intravenous infusion was used initially in all patients and changed to Bivalirudin in 2 patients due to possible HIT. Pump flow ranged from 2.6 to 6.5 L/min. Average support time was 12 days (range 2–24 days). Seven patients (63.3%) were successfully separated from ECMO and survived to hospital discharge. Hospital length of stay ranged from 3 to 42 days, tracheostomy was done percutaneously in 5 patients and surgically in 3. Gastrointestinal bleeding occurred in 6 patients, VAP in 7 patients, neurologic complications in 1 patient with complete recovery, cardiac arrhythmias in 3 patients, pneumothorax in 9 patients, and deep venous thrombosis in 2 patients

Epidemiology of surgery associated acute kidney injury (EPIS-AKI): a prospective international observational multi-center clinical study

Purpose: The incidence, patient features, risk factors and outcomes of surgery-associated postoperative acute kidney injury (PO-AKI) across different countries and health care systems is unclear. Methods: We conducted an international prospective, observational, multi-center study in 30 countries in patients undergoing major surgery (&gt; 2-h duration and postoperative intensive care unit (ICU) or high dependency unit admission). The primary endpoint was the occurrence of PO-AKI within 72&nbsp;h of surgery defined by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Secondary endpoints included PO-AKI severity and duration, use of renal replacement therapy (RRT), mortality, and ICU and hospital length of stay. Results: We studied 10,568 patients and 1945 (18.4%) developed PO-AKI (1236 (63.5%) KDIGO stage 1500 (25.7%) KDIGO stage 2209 (10.7%) KDIGO stage 3). In 33.8% PO-AKI was persistent, and 170/1945 (8.7%) of patients with PO-AKI received RRT in the ICU. Patients with PO-AKI had greater ICU (6.3% vs. 0.7%) and hospital (8.6% vs. 1.4%) mortality, and longer ICU (median 2 (Q1-Q3, 1-3) days vs. 3 (Q1-Q3, 1-6) days) and hospital length of stay (median 14 (Q1-Q3, 9-24) days vs. 10 (Q1-Q3, 7-17) days). Risk factors for PO-AKI included older age, comorbidities (hypertension, diabetes, chronic kidney disease), type, duration and urgency of surgery as well as intraoperative vasopressors, and aminoglycosides administration. Conclusion: In a comprehensive multinational study, approximately one in five patients develop PO-AKI after major surgery. Increasing severity of PO-AKI is associated with a progressive increase in adverse outcomes. Our findings indicate that PO-AKI represents a significant burden for health care worldwide

Acute kidney disease beyond day 7 after major surgery: a secondary analysis of the EPIS-AKI trial

Purpose: Acute kidney disease (AKD) is a significant health care burden worldwide. However, little is known about this complication after major surgery. Methods: We conducted an international prospective, observational, multi-center study among patients undergoing major surgery. The primary study endpoint was the incidence of AKD (defined as new onset of estimated glomerular filtration rate (eCFR) &lt; 60&nbsp;ml/min/1.73&nbsp;m2 present on day 7 or later) among survivors. Secondary endpoints included the relationship between early postoperative acute kidney injury (AKI) (within 72&nbsp;h after major surgery) and subsequent AKD, the identification of risk factors for AKD, and the rate of chronic kidney disease (CKD) progression in patients with pre-existing CKD. Results: We studied 9510 patients without pre-existing CKD. Of these, 940 (9.9%) developed AKD after 7&nbsp;days of whom 34.1% experiencing an episode of early postoperative-AKI. Rates of AKD after 7&nbsp;days significantly increased with the severity (19.1% Kidney Disease Improving Global Outcomes [KDIGO] 1, 24.5% KDIGO2, 34.3% KDIGO3; P &lt; 0.001) and duration (15.5% transient vs 38.3% persistent AKI; P &lt; 0.001) of early postoperative-AKI. Independent risk factors for AKD included early postoperative-AKI, exposure to perioperative nephrotoxic agents, and postoperative pneumonia. Early postoperative-AKI carried an independent odds ratio for AKD of 2.64 (95% confidence interval [CI] 2.21-3.15). Of 663 patients with pre-existing CKD, 42 (6.3%) had worsening CKD at day 90. In patients with CKD and an episode of early AKI, CKD progression occurred in 11.6%. Conclusion: One in ten major surgery patients developed AKD beyond 7&nbsp;days after surgery, in most cases without an episode of early postoperative-AKI. However, early postoperative-AKI severity and duration were associated with an increased rate of AKD and early postoperative-AKI was strongly associated with AKD independent of all other potential risk factors