We present a case of leiomyomatosis peritonealis disseminata (LPD) after myoma morcellation and r... more We present a case of leiomyomatosis peritonealis disseminata (LPD) after myoma morcellation and review the literature using the keywords leiomyomatosis peritonealis disseminata and disseminated peritoneal leiomyomatosis. The search was conducted in Medline, EMBASE, and Cochrane Database of systematic reviews. We encountered 132 cases of LPD in the English literature; 113 in the reproductive age group, 7 in postmenopausal women, 6 in males, and another in a horse. The possible causes could be divided into hormonal, subperitoneal mesenchymal stem cells, metaplasia, genetic, or iatrogenic after morcellation of myoma during laparoscopic surgery. Our case and 4 others reported in the literature support the contribution of the iatrogenic theory. It appears that LPD could be due to metaplasia of mesenchymal cells of the peritoneum and, in susceptible women, leaving fragments of myoma in the abdominal cavity might contribute to the development of LPD. Accordingly, one should avoid leaving fragments of the uterus or myoma tissue in the abdominal cavity after morcellation.
To identify the risk factors predictive of conversion of laparoscopic cholecystectomy to open sur... more To identify the risk factors predictive of conversion of laparoscopic cholecystectomy to open surgery. Demographic, ultrasonographic, and operative data of patients who underwent laparoscopic cholecystectomy were analyzed. Factors affecting conversion to open surgery were identified with statistical analysis. A tertiary referral center. Five hundred patients who underwent laparoscopic cholecystectomies at our institution between March 1991 and July 1994. The patients' data had been prospectively collected. Standard laparoscopic techniques with selective preoperative endoscopic retrograde cholangiopancreatography. Conversion of laparoscopic cholecystectomy to open surgery for management of technical difficulties or intraoperative complications. Increased risk of conversion with statistical significance was found in patients older than 65 years, obese patients, patients who underwent interval elective laparoscopic cholecystectomy for acute cholecystitis, patients with ultrasonographic findings of thickened gallbladder wall, patients seen during the early learning phase of the series, and patients whose surgery was performed by senior surgeons. Increased risk of conversion was not found with patients' sex, previous lower abdominal surgery, history of acute pancreatitis or cholangitis, impaired liver function on presentation, or emergency laparoscopic cholecystectomy for acute cholecystitis. Risk factors, including patient factors, presentation, preoperative ultrasonography, and surgical experience, all contributed to the possibility of conversion. Knowledge of these factors may help in arranging the operating schedule, psychological preparation for the procedure, and planning of the duration of convalescence.
Acta Obstetricia et Gynecologica Scandinavica, 2010
We evaluated the operative and postoperative morbidity among 103 women who underwent total laparo... more We evaluated the operative and postoperative morbidity among 103 women who underwent total laparoscopic hysterectomy and 107 others who underwent laparoscopically assisted vaginal hysterectomy. Blood loss was significantly greater in the assisted vaginal hysterectomy group (178.0 ± 12.1 ml) than in the total hysterectomy group (130.2 ± 10.7 ml) (p < 0.001). Despite higher uterine weight in the total hysterectomy group, the operative time of both techniques was similar. The complications of both hysterectomies were also comparable. The results from our study suggest that the complication rates of laparoscopically assisted vaginal hysterectomy and total hysterectomy are similar. However, laparoscopically assisted vaginal hysterectomy is associated with increased blood loss.
Sultan Qaboos University Medical Journal, Dec 1, 2009
Leiomyomatosis peritonealis disseminata (LPD), also known as diffuse peritoneal leiomyomatosis, i... more Leiomyomatosis peritonealis disseminata (LPD), also known as diffuse peritoneal leiomyomatosis, is a rare disease characterised by subperitoneal proliferation of benign nodules mainly composed of benign smooth muscle cells, macroscopically mimicking peritoneal carcinomatosis. We report a 43 year-old woman who presented with menorrhagia, pelvic pressure and pain. Ultrasound of the pelvis showed uterine fibroids and an ovarian cyst. She was scheduled to have a laparoscopic hysterectomy and left salpingo-oophorectomy for symptomatic relief. A picture of carcinomatosis was seen on laparoscopy so multiple biopsies were taken and the patient was referred to the gynaecological oncology team. Definitive surgery was performed and final pathology was consistent with LPD with no evidence of malignancy. No hormone replacement therapy was offered after surgery. Macroscopically, LPD has features of malignancy; it usually pursues a benign course. To review current management of LPD and the risk of malignant transformation, we conducted a search in Medline, EMBASE, and the Cochrane Database of systematic reviews using the keywords: leiomyomatosis peritonealis disseminata, management and malignant transformation. LPD is a diagnostic challenge. Although rare, malignant transformation can occur since hormones play an important role in the pathogenesis of LPD, following surgery, patients should be followed carefully if they are on hormone replacement as these tumours could re-grow and cause symptoms or transform to malignancy.
Sultan Qaboos University Medical Journal, Nov 1, 2008
... INTERESTINGMEDICALIMA GE Department of Obstetrics and Gynaecology, McGill University, Montrea... more ... INTERESTINGMEDICALIMA GE Department of Obstetrics and Gynaecology, McGill University, Montreal, Canada *To whom correspondence should be addressed. Email: ayman.altalib@gmail. com Figure 1: Clitoromegaly Figure 2: Steriod cell tumor gross appearance ...
Malignant transformation is an infrequent complication of endometriosis. As endometriosis is an e... more Malignant transformation is an infrequent complication of endometriosis. As endometriosis is an ectopic endometrium, hyperestrogenism may cause hyperplasia or transformation into cancer. We describe a case of a 68-year-old woman who underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy for endometriosis. She was subsequently placed on estrogen-only replacement therapy. She presented with left-sided pelvic mass and shortness of breath. Computed tomography of chest, pelvis, and abdomen, demonstrated right-sided pleural effusion and soft tissue mass in the pelvis. Pleural effusion was tapped and biopsy from the peritoneal mass showed metastatic adenocarcinoma; immunohistochemistry findings favored endometrioid adenocarcinoma. She was treated by 6 cycles of Carboplatin/Paclitaxel and responded well. Unopposed estrogen stimulation may lead to premalignant or malignant transformation in the residual foci of endometriosis. Therefore, the addition of progestins to estro...
Laparoscopic myomectomy is one of the best treatment options for women with symptomatic fibroids ... more Laparoscopic myomectomy is one of the best treatment options for women with symptomatic fibroids who wish to maintain their fertility. Compared with myomectomy by laparotomy, the laparoscopic approach is associated with shorter hospital stay, faster recovery, less postoperative pain, and reduced adhesion formation. Laparoscopic myomectomy is technically challenging, and occasionally the procedure needs to be completed by laparotomy. In this review, I will describe my team's experience with laparoscopic myomectomy and discuss factors contributing to failure. The most important factors affecting conversion of a laparoscopic myomectomy to laparotomy are patient selection and the laparoscopic expertise of the surgeon. Each surgeon should determine his or her criteria for laparoscopic myomectomy. Other factors include posterior intramural location, soft consistency associated with the use of gonadotropin releasing hormone agonist (GnRHa), the diameter of the dominant myoma, and the w...
To examine the relationship between the umbilicus, major abdominal vessels, and transverse colon ... more To examine the relationship between the umbilicus, major abdominal vessels, and transverse colon in males with differing body habitus, we conducted a prospective study including 91 male patients who underwent computerized tomography scan examinations. Of 91 males, 40 were normal weight, 27 overweight, and 24 obese. Compared with males of normal weight, the distance between the umbilicus and peritoneum was significantly greater in those who were overweight and obese. In males in whom the umbilicus was located cephalad to the aortic bifurcation, the distance was 1.4 to 2 cm. There was no significant difference in the distance among those who were normal weight, overweight, or obese. In males whose umbilicus was caudal to the aortic bifurcation, the distance in obese males (2.3±0.3 cm) was significantly greater than in those with normal weight (1.2±0.2 cm; P<0.01). Compared with normal weight males (8.6±0.7 cm), the distance between the umbilicus and transverse colon was significant...
This was a prospective study of postmenopausal women who underwent a computerized tomography (CT)... more This was a prospective study of postmenopausal women who underwent a computerized tomography (CT) examination of the abdomen and pelvis. We evaluated the location of the aortic bifurcation and transverse colon relative to the umbilicus at midline axis. Of 66 women, 24 were of normal weight, 23 were classified as overweight, and 19 as obese. The ages of the women in all groups were comparable. In the normal weight and overweight women, the mean location of the umbilicus was 0.6 cm +/- 0.4 cm and 0.4 cm +/- 0.3 cm cranial to the aortic bifurcation, respectively, and in obese women its mean location was 1.4 cm +/- 0.5 cm caudal to the aortic bifurcation. In approximately half of the normal weight and overweight women, the umbilicus was located cranial to the aortic bifurcation, and in 62.2% of obese women it was located caudal to the aortic bifurcation. Compared to those with normal weight (0.3 cm +/- 1.1 cm), the distance between umbilicus and transverse colon was greater in overweigh...
To evaluate the predisposing factors and treatment outcomes of different stages of intrauterine a... more To evaluate the predisposing factors and treatment outcomes of different stages of intrauterine adhesions. We examined the medical records of women with Asherman syndrome seen during the period of January 2000 to December 2007 at two McGill University teaching hospitals in Montreal. Data retrieved included patient&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s age, menstrual pattern, fertility, factors related to intrauterine adhesions, and rates of amenorrhea and pregnancy at 12-month follow-up. The diagnosis was established by hysteroscopic examination. After confirmation of the diagnosis, the intrauterine adhesions were removed using a standard technique with a loop electrode and glycine 1.5% as distension medium. In cases with severe intrauterine adhesions, abdominal ultrasound was used to ensure that the uterine cavity was not breached. At the completion of each procedure a number 16 Foley catheter with 5 mL of normal saline in the bulb was placed in the uterine cavity and removed five days later. In addition, vaginal estradiol 17 beta was administered three times daily for four weeks with oral progesterone administered in the fourth week of estradiol treatment. Of 65 patients, we identified 24 with stage I intrauterine adhesions (36.9%), 30 with stage II (46.2%), and 11 with stage III (16.9%). The main reasons for referral were infertility (stage I 75%, stage II 73.3%, stage III 27.3%), and amenorrhea (stage I 25%, stage II 23.3%, stage III 72.7%). The main predisposing factor was dilatation and curettage. Of 40 patients with intrauterine adhesions related to early pregnancy curettage, 18 patients (45%) had stage I adhesions, 17 (42.5%) had stage II, and five (12.5%) had stage III. This contrasted with 10 patients who had peripartum curettage, in whom six (60%) developed stage III adhesions (P = 0.004). The rate of amenorrhea was 32.3% before adhesiolysis and 9.2% after. Among 43 women who wished to conceive, the pregnancy rate was 51.2% and the live birth rate 32.6%. The main reasons for referral of women with intrauterine adhesions are infertility and amenorrhea. Postpartum curettage leads to severe adhesions. The rates of pregnancy and term pregnancy among this selected group of women were similar regardless of the severity of adhesions.
We present a case of leiomyomatosis peritonealis disseminata (LPD) after myoma morcellation and r... more We present a case of leiomyomatosis peritonealis disseminata (LPD) after myoma morcellation and review the literature using the keywords leiomyomatosis peritonealis disseminata and disseminated peritoneal leiomyomatosis. The search was conducted in Medline, EMBASE, and Cochrane Database of systematic reviews. We encountered 132 cases of LPD in the English literature; 113 in the reproductive age group, 7 in postmenopausal women, 6 in males, and another in a horse. The possible causes could be divided into hormonal, subperitoneal mesenchymal stem cells, metaplasia, genetic, or iatrogenic after morcellation of myoma during laparoscopic surgery. Our case and 4 others reported in the literature support the contribution of the iatrogenic theory. It appears that LPD could be due to metaplasia of mesenchymal cells of the peritoneum and, in susceptible women, leaving fragments of myoma in the abdominal cavity might contribute to the development of LPD. Accordingly, one should avoid leaving fragments of the uterus or myoma tissue in the abdominal cavity after morcellation.
To identify the risk factors predictive of conversion of laparoscopic cholecystectomy to open sur... more To identify the risk factors predictive of conversion of laparoscopic cholecystectomy to open surgery. Demographic, ultrasonographic, and operative data of patients who underwent laparoscopic cholecystectomy were analyzed. Factors affecting conversion to open surgery were identified with statistical analysis. A tertiary referral center. Five hundred patients who underwent laparoscopic cholecystectomies at our institution between March 1991 and July 1994. The patients&amp;amp;#39; data had been prospectively collected. Standard laparoscopic techniques with selective preoperative endoscopic retrograde cholangiopancreatography. Conversion of laparoscopic cholecystectomy to open surgery for management of technical difficulties or intraoperative complications. Increased risk of conversion with statistical significance was found in patients older than 65 years, obese patients, patients who underwent interval elective laparoscopic cholecystectomy for acute cholecystitis, patients with ultrasonographic findings of thickened gallbladder wall, patients seen during the early learning phase of the series, and patients whose surgery was performed by senior surgeons. Increased risk of conversion was not found with patients&amp;amp;#39; sex, previous lower abdominal surgery, history of acute pancreatitis or cholangitis, impaired liver function on presentation, or emergency laparoscopic cholecystectomy for acute cholecystitis. Risk factors, including patient factors, presentation, preoperative ultrasonography, and surgical experience, all contributed to the possibility of conversion. Knowledge of these factors may help in arranging the operating schedule, psychological preparation for the procedure, and planning of the duration of convalescence.
Acta Obstetricia et Gynecologica Scandinavica, 2010
We evaluated the operative and postoperative morbidity among 103 women who underwent total laparo... more We evaluated the operative and postoperative morbidity among 103 women who underwent total laparoscopic hysterectomy and 107 others who underwent laparoscopically assisted vaginal hysterectomy. Blood loss was significantly greater in the assisted vaginal hysterectomy group (178.0 ± 12.1 ml) than in the total hysterectomy group (130.2 ± 10.7 ml) (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). Despite higher uterine weight in the total hysterectomy group, the operative time of both techniques was similar. The complications of both hysterectomies were also comparable. The results from our study suggest that the complication rates of laparoscopically assisted vaginal hysterectomy and total hysterectomy are similar. However, laparoscopically assisted vaginal hysterectomy is associated with increased blood loss.
Sultan Qaboos University Medical Journal, Dec 1, 2009
Leiomyomatosis peritonealis disseminata (LPD), also known as diffuse peritoneal leiomyomatosis, i... more Leiomyomatosis peritonealis disseminata (LPD), also known as diffuse peritoneal leiomyomatosis, is a rare disease characterised by subperitoneal proliferation of benign nodules mainly composed of benign smooth muscle cells, macroscopically mimicking peritoneal carcinomatosis. We report a 43 year-old woman who presented with menorrhagia, pelvic pressure and pain. Ultrasound of the pelvis showed uterine fibroids and an ovarian cyst. She was scheduled to have a laparoscopic hysterectomy and left salpingo-oophorectomy for symptomatic relief. A picture of carcinomatosis was seen on laparoscopy so multiple biopsies were taken and the patient was referred to the gynaecological oncology team. Definitive surgery was performed and final pathology was consistent with LPD with no evidence of malignancy. No hormone replacement therapy was offered after surgery. Macroscopically, LPD has features of malignancy; it usually pursues a benign course. To review current management of LPD and the risk of malignant transformation, we conducted a search in Medline, EMBASE, and the Cochrane Database of systematic reviews using the keywords: leiomyomatosis peritonealis disseminata, management and malignant transformation. LPD is a diagnostic challenge. Although rare, malignant transformation can occur since hormones play an important role in the pathogenesis of LPD, following surgery, patients should be followed carefully if they are on hormone replacement as these tumours could re-grow and cause symptoms or transform to malignancy.
Sultan Qaboos University Medical Journal, Nov 1, 2008
... INTERESTINGMEDICALIMA GE Department of Obstetrics and Gynaecology, McGill University, Montrea... more ... INTERESTINGMEDICALIMA GE Department of Obstetrics and Gynaecology, McGill University, Montreal, Canada *To whom correspondence should be addressed. Email: ayman.altalib@gmail. com Figure 1: Clitoromegaly Figure 2: Steriod cell tumor gross appearance ...
Malignant transformation is an infrequent complication of endometriosis. As endometriosis is an e... more Malignant transformation is an infrequent complication of endometriosis. As endometriosis is an ectopic endometrium, hyperestrogenism may cause hyperplasia or transformation into cancer. We describe a case of a 68-year-old woman who underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy for endometriosis. She was subsequently placed on estrogen-only replacement therapy. She presented with left-sided pelvic mass and shortness of breath. Computed tomography of chest, pelvis, and abdomen, demonstrated right-sided pleural effusion and soft tissue mass in the pelvis. Pleural effusion was tapped and biopsy from the peritoneal mass showed metastatic adenocarcinoma; immunohistochemistry findings favored endometrioid adenocarcinoma. She was treated by 6 cycles of Carboplatin/Paclitaxel and responded well. Unopposed estrogen stimulation may lead to premalignant or malignant transformation in the residual foci of endometriosis. Therefore, the addition of progestins to estro...
Laparoscopic myomectomy is one of the best treatment options for women with symptomatic fibroids ... more Laparoscopic myomectomy is one of the best treatment options for women with symptomatic fibroids who wish to maintain their fertility. Compared with myomectomy by laparotomy, the laparoscopic approach is associated with shorter hospital stay, faster recovery, less postoperative pain, and reduced adhesion formation. Laparoscopic myomectomy is technically challenging, and occasionally the procedure needs to be completed by laparotomy. In this review, I will describe my team's experience with laparoscopic myomectomy and discuss factors contributing to failure. The most important factors affecting conversion of a laparoscopic myomectomy to laparotomy are patient selection and the laparoscopic expertise of the surgeon. Each surgeon should determine his or her criteria for laparoscopic myomectomy. Other factors include posterior intramural location, soft consistency associated with the use of gonadotropin releasing hormone agonist (GnRHa), the diameter of the dominant myoma, and the w...
To examine the relationship between the umbilicus, major abdominal vessels, and transverse colon ... more To examine the relationship between the umbilicus, major abdominal vessels, and transverse colon in males with differing body habitus, we conducted a prospective study including 91 male patients who underwent computerized tomography scan examinations. Of 91 males, 40 were normal weight, 27 overweight, and 24 obese. Compared with males of normal weight, the distance between the umbilicus and peritoneum was significantly greater in those who were overweight and obese. In males in whom the umbilicus was located cephalad to the aortic bifurcation, the distance was 1.4 to 2 cm. There was no significant difference in the distance among those who were normal weight, overweight, or obese. In males whose umbilicus was caudal to the aortic bifurcation, the distance in obese males (2.3±0.3 cm) was significantly greater than in those with normal weight (1.2±0.2 cm; P<0.01). Compared with normal weight males (8.6±0.7 cm), the distance between the umbilicus and transverse colon was significant...
This was a prospective study of postmenopausal women who underwent a computerized tomography (CT)... more This was a prospective study of postmenopausal women who underwent a computerized tomography (CT) examination of the abdomen and pelvis. We evaluated the location of the aortic bifurcation and transverse colon relative to the umbilicus at midline axis. Of 66 women, 24 were of normal weight, 23 were classified as overweight, and 19 as obese. The ages of the women in all groups were comparable. In the normal weight and overweight women, the mean location of the umbilicus was 0.6 cm +/- 0.4 cm and 0.4 cm +/- 0.3 cm cranial to the aortic bifurcation, respectively, and in obese women its mean location was 1.4 cm +/- 0.5 cm caudal to the aortic bifurcation. In approximately half of the normal weight and overweight women, the umbilicus was located cranial to the aortic bifurcation, and in 62.2% of obese women it was located caudal to the aortic bifurcation. Compared to those with normal weight (0.3 cm +/- 1.1 cm), the distance between umbilicus and transverse colon was greater in overweigh...
To evaluate the predisposing factors and treatment outcomes of different stages of intrauterine a... more To evaluate the predisposing factors and treatment outcomes of different stages of intrauterine adhesions. We examined the medical records of women with Asherman syndrome seen during the period of January 2000 to December 2007 at two McGill University teaching hospitals in Montreal. Data retrieved included patient&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s age, menstrual pattern, fertility, factors related to intrauterine adhesions, and rates of amenorrhea and pregnancy at 12-month follow-up. The diagnosis was established by hysteroscopic examination. After confirmation of the diagnosis, the intrauterine adhesions were removed using a standard technique with a loop electrode and glycine 1.5% as distension medium. In cases with severe intrauterine adhesions, abdominal ultrasound was used to ensure that the uterine cavity was not breached. At the completion of each procedure a number 16 Foley catheter with 5 mL of normal saline in the bulb was placed in the uterine cavity and removed five days later. In addition, vaginal estradiol 17 beta was administered three times daily for four weeks with oral progesterone administered in the fourth week of estradiol treatment. Of 65 patients, we identified 24 with stage I intrauterine adhesions (36.9%), 30 with stage II (46.2%), and 11 with stage III (16.9%). The main reasons for referral were infertility (stage I 75%, stage II 73.3%, stage III 27.3%), and amenorrhea (stage I 25%, stage II 23.3%, stage III 72.7%). The main predisposing factor was dilatation and curettage. Of 40 patients with intrauterine adhesions related to early pregnancy curettage, 18 patients (45%) had stage I adhesions, 17 (42.5%) had stage II, and five (12.5%) had stage III. This contrasted with 10 patients who had peripartum curettage, in whom six (60%) developed stage III adhesions (P = 0.004). The rate of amenorrhea was 32.3% before adhesiolysis and 9.2% after. Among 43 women who wished to conceive, the pregnancy rate was 51.2% and the live birth rate 32.6%. The main reasons for referral of women with intrauterine adhesions are infertility and amenorrhea. Postpartum curettage leads to severe adhesions. The rates of pregnancy and term pregnancy among this selected group of women were similar regardless of the severity of adhesions.
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