Get inside to spot the BIG moves in SMALL COMPANIES SMALL "This year was our fiscal cliff. FY14 is when we realise all the hard work from our stategy. " Richard Pang, CEO ISS Group Welcome back to another year of Under the Radar. SHARE RESEARCH Tip 1. p2 mAynE pHARmA (myx)
Hers.krOpen Journal of Obstetrics and Gynecology, 2012, 2, 127-130 OJOG
doi:10.4236/ojog.2012.22024 Published Online June 2012 (http://www.SciRP.org/journal/ojog/)
Cornual patency and integrity following laparoscopic
cornuotomy for interstitial pregnancy
Young-Sam Choi, Dae-Sook Eun, Yun-Sang Oh, Ji-No Park
Department of Obstetrics and Gynecology of Eun Hospital, Kwang-Ju Metropolitan City, South Korea Ema Received 29 March 2012; revised 23 April 2012; accepted 3 May 2012 ABSTRACT
modified laparoscopic surgical technique for interstitial pregnancy in the preceding paper. The method termi- Objective: To evaluate cornual patency and integrity
nated the interstitial pregnancy without major complica- following laparoscopic cornuotomy. Study Design: This
tions and had potential probability for preservation of the is a prospective cohort study on seven women who
affected cornu and salpinx . In this study, we present underwent laparoscopic cornuotomy for interstitial
the cornual patency and integrity after laparoscopic cor- pregnancy. The cornual patency and integrity were
nuotomy for interstitial pregnancy. evaluated using hysterosalpingography (HSG) and
magnetic resonance imaging (MRI). On MRI, the en-
2. MATERIALS AND METHODS
tire cornual wall thickness were measured bilater-
ally at 5-mm intervals. The thickness of the affected
This is a prospective cohort study on seven of eight and unaffected cornua matched at the corresponding
women who underwent laparoscopic cornuotomy for contralateral point in each of the women. Statistically,
interstitial pregnancy at Eun Hospital between February all possible pairwise 28 comparisons were compared
2005 and November 2006. As described in the preceding using paired t-tests. Results: Among six eligible women,
paper, the laparoscopic cornuotomy was performed using four women had excellent cornual patency on the af-
a temporary tourniquet suture with injection of diluted fected side. Among seven women (i.e., 28 pairs), no
vasopressin. Sufficient diluted vasopressin was injected significant difference was observed in cornual thick-
around the cornual mass and a circumferential intra- ness compared to the unaffected cornu and no re-
myometrial tourniquet suture was made around the me- markable defects were seen in the endometrial and
dial part of the protruding mass. After placement, the two cornual contour. But there is no statistical signifi-
ends of the suture were tightened and a knot was tied cance. Conclusion: Laparoscopic cornuotomy seems
while maintaining tension to produce a tourniquet effect. to have advantage to preserve the cornu in interstitial
Additional dilute vasopressin solution was injected into pregnancy.
the protruding cornual mass. Then, the cornua was in- Keywords: Interstitial Pregnancy; Cornual Pregnancy;
cised, the conceptus evacuated, and the cornua repaired. Cornuotomy; Outcome; Cornual Integrity Finally, the tourniquet suture was cut and removed com- pletely after the cornual repair.  The contour of the endometrial cavity and cornual 1. INTRODUCTION
patency were evaluated using hysterosalpingography Interstitial pregnancy refers to an ectopic pregnancy (HSG), and the cornual integrity was assessed with mag- which the fertilized ovum is implanted in the interstitial netic resonance image (MRI). Images were obtained be- segment of the fallopian tube. This rare entity can trigger tween 3 and 25 months postoperatively and interpreted a life-threatening hemorrhage due to the anatomical fea- by a radiologist blinded to the clinical data, except for tures of the interstitial segment but that is mere begin- name and age. Cornual patency could not be evaluated ning of successive disasters such as reduced fertility or on HSG in two women: case no. 6, who had undergone a uterine rupture in the subsequent pregnancy. In the last previous ipsilateral salpingectomy for tubal pregnancy, two decades, various conservative management methods and case no. 8, who was lost to follow-up. The cornual have been investigated and advanced in treating intersti- integrity could not be evaluated on MRI in one woman: tial pregnancy [1-8]. But our greatest concern is how to case no. 8, who was lost to follow-up. minimize the additional destruction of the innate fertile On axial and coronal views of T1- and T2-weighted structure beyond minimal invasiveness. We introduced a images, the entire cornual wall thickness was measured Published Online June 2012 in SciRes. http://www.scirp.org/journal/ojog Y.-S. Choi et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 127-130 bilaterally at 5-mm intervals and the entire cornual con- tour was observed closely. The thickness of the affected and unaffected cornua matched the corresponding con- tralateral point in each of the women. Statistically, all possible pairwise comparisons of the seven patients (i.e., 28 pairs) were made using paired t-tests. 3. RESULTS
Figure 2. Magnetic resonance images that were obtained 3
Figures 1 and 2 are HSG and MRI respectively that were
months following laparoscopic cornuotomy for interstitial preg- obtained after 3 months postoperatively (case no. 2). nancy. (A) Axial view on the T2-weighted image; (B) Coronal As shown in Figure 1, both tubes are patent (arrow-
view on the T2-weighted image. The arrowhead and opened arrow indicate the affected cornu. Note that there are no sig- heads) and that contrast material spills into the peritoneal nificant differences in the thickness of the affected and un- cavity (open arrow). Small internal projection (straight affected cornu, and no defects in terms of the overall cornual arrow) is revealed on the affected right proximal cornu, contour. (case no. 2). but is negligible in terms of the overall cornual patency. In Figure 2, Arrowhead and open arrow indicate the af-
women (cases no. 1 and 4). Two women (cases no. 2 and fected cornu. There are no significant differences in the 5) had small internal projection at the affected cornu, but thickness of the affected and unaffected cornu, and no these were negligible in terms of the overall cornual defects in terms of the overall cornual contour. patency. No remarkable distortion of the endometrial As shown in Table 1, four of the six eligible women
cavity was detected and the endometrial contour was (two women were excluded: case no. 6, who had under- gone a previous ipsilateral salpingectomy for tubal preg- In cornual thickness category of Table 1, the top and
nancy, and case no. 8, who was lost to follow-up) had bottom lines indicate the thicknesses of the affected and excellent cornual patency on the side affected by the in- corresponding contralateral unaffected points on MRI terstitial pregnancy on HSG, while tubal occlusion at the respectively. The difference in cornual thickness was not affected proximal cornu occurred in the remaining two significant and no remarkable defects in the overall cor- nual contour were observed. But there is no statistical significance. The lack of statistical significance probably resulted from the small sample size (p = 0.49, paired t-test). 4. DISCUSSION
Laparoscopic surgery is the preferred surgical approach for a variety of gynecologic conditions. Although the laparoscopic assessment of interstitial pregnancy was once deemed hazardous due to the ana- tomical features of the interstitial segment but that is far from the fact today. Moreover, concern has shifted from minimal invasiveness toward minimizing the subsequent effects on the patient's fertility [5-9]. Moon and colleagues reported their laparoscopic tech- niques and the outcomes using an encircling suture and endoloop ligation. Their techniques were very worthy in terms of technical simplicity and effectiveness; in addi- tion, they reported subsequent pregnancy after long-term follow-up and clinical outcomes including the cornual state through Caesarean section at full term . To our Figure 1. HSG that was obtained 3 months following laparo-
knowledge, this is the first report on the outcomes of scopic cornuotomy for interstitial pregnancy. Notice that both subsequent pregnancies after the conservative manage- tubes are patent (arrowheads) and that contrast material spills ment of interstitial pregnancy. But in their procedures, into the peritoneal cavity (opened arrow). Small external dim- pling (straight arrow) is revealed on the affected right proximal affected cornu were ligated and the encircling suture or cornu, but is negligible in terms of the overall cornual patency endoloop was left intact, consequently, the affected cornu and salpinx was sacrificed anatomically or functionally Copyright 2012 SciRes. OJOG
Y.-S. Choi et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 127-130 Table 1. Summary of the cornual patency and integrity the patients who underwent laparoscopic cornuotomy for interstitial preg-
Thickness of cornu (mm) Affected side (top) Unaffected side (bottom) p = 0.49d a) NS: non-specific; b) NA1: non-applicable 1 due to previous salpingectomy; c) NA2: non-applicable 2 due to lost to follow up; d) paired t-test. . In contrast, with our technique, the tourniquet suture dition, no information was available on the distended was cut and removed completely after the cornual repair, pregnant uterus. If a subsequent caesarean section were so that it did not interfere with the blood supply or required at full term, evaluation of the uterine integrity patency of the affected cornu and salpinx and get a po- precisely would be possible. However, we have not yet tential opportunity for preserving their function . encountered this situation. Assessing the anatomic repro- An alternative form of noninvasive management is ductive capacity, especially the myometrial integrity us- medical treatment, which includes systemic or local ing MRI, may not be sufficient. Nevertheless, as previ- methotrexate, KCl, hypertonic dextrose, prostaglandins, ously reported, MRI has demonstrated uterine defects in or actinomycin D. Although no controlled study has de- previous Caesarean scars and HSG is considered the gold termined the superior drug, methotrexate is most often standard for imaging the endometrial contour and tubal used in medical treatment. Methotrexate treatment is patency [12-14]. Therefore, these imaging techniques have noninvasive, but has several disadvantages, including the proven to be valuable, alternative, noninvasive tools for need for prolonged close follow-up and an overall suc- evaluating the endometrial contour, myometrial integrity, cess rate of only 83% (91% with local injection, 79% and tubal patency. with systemic injection) . Treatment failure can trigger In our series, the tube in the affected proximal cornu life-threatening hemorrhage; furthermore, the Metho- was occluded in two women (cases no. 1 and 4). After trxate has teratogenic effects in subsequent pregnancies reviewing the videotapes of the two women, we found and cannot be used to treat hemodynamically unstable that accidental tubal ligation occurred due to excessive women [1-5,10,11]. lateral extension and deep needle penetration during the Our study has several limitations as follows; it was an cornual repair in both cases. Meticulous full-thickness uncontrolled study, with a small number of cases. In ad- suturing is very important for hemostasis and maintain- Copyright 2012 SciRes. OJOG
Y.-S. Choi et al. / Open Journal of Obstetrics and Gynecology 2 (2012) 127-130 ing uterine integrity, but excessive deep needle penetra- tion can cause accidental tubal ligation. Consequently,  Weissman, A. and Fishman, A. (1992) Uterine rupture careful repair of the proximal cornu is very important for following conservative surgery for interstitial pregnancy. avoiding iatrogenic tubal injury. European Journal of Obstetrics & Gynecology and Re- Interestingly, the right cornu was involved in all cases, productive Biology, 44, 237-239.
but whether an unknown pathophysiology was at play or this was mere coincidence is uncertain. In addition, the  Lau, S. and Tulandi, T. (1999) Conservative medical and surgical management of interstitial ectopic pregnancy. superiority of a transverse versus vertical incision has not Fertility & Sterility, 72, 207-215.
been determined. A transverse incision can be extended laterally if needed and it reduces blood vessel injury be-  Chetty, M. and Elson, J. (2009) Treating non-tubal ec- cause the direction parallels the cornual collateral vessels; topic pregnancy. Best Practice & Research Clinical Ob- however, this direction may induce iatrogenic tubal in- stetrics & Gynecology, 23, 529-538.
 Moon, H.S., Choi, Y.J., Park, Y.H. and Kim, S.G. (2000) Since interstitial pregnancy is very rare, a worldwide New simple endoscopic operations for interstitial preg- registry is needed to verify the efficiency and outcome of nancies. American Journal of Obstetrics & Gynecology, various treatment methods. This registry should include 182, 114-121.
prospective long-term follow-up data on patients with  Choi, Y.S., Eun, D.S., Choi, J., Shin, K.S., Choi, J.H. and interstitial pregnancy and retrospective data on pregnant Park, H.D. (2009) Laparoscopic cornuotomy using a tem- women who have been managed previously. With the porary tourniquet suture and diluted vasopressin injection accumulation of clinical data and large-scale studies such in interstitial pregnancy. Fertility and Sterility, 91, 1933-
as meta-analyses, many questions can be answered. Three of our multiparous women conceived 12, 17,  Ross, R., Lindheim, S.R., Olive, D.L. and Pritts, E.A. (2006) Cornual gestation: A systematic literature review and 40 months after the surgery, respectively and, to our and two case reports of a novel treatment regimen. Jour- surprise, all were delivered safely via the vaginal route at nal of Minimally Invasive Gynecology, 13, 74-78.
full term. One nulliparous woman conceived 30 months after the surgery, but she was lost to follow-up after 30  Lloyd, M.E., Carr, M., McElhatton, P., Hall, G.M. and weeks of pregnancy. Hughes, R.A. (1999) The effects of methotrexate on preg- nancy, fertility and lactation. QJM: An International Jour- nal of Medicine, 92, 551-563.
 Khaled, A.M., Mohamed, H., Ahmed, S., Heba, El.-S. and  Damario, M.A. and Rock, J.A. (2003) Surgery for obstet- Amr, O.A. (2005) A prospective comparative study to as- rics: Ectopic pregnancy. In: Te Linde's Operative Gyne- sess the accuracy of MRI versus HSG in tubouterine cology, 9th Edition, Lippincott-Williams & Wilkins Inc., causes of female infertility. Middle East Fertility Society Philadelphia, 798-824. Journal, 10, 250-257.
 Dialani, V. and Levine, D. (2004) Ectopic pregnancy: A  Donnez, O., Jadoul, P., Squifflet, J. and Donnez, J. (2008) review. Ultrasound Quarterly, 20, 105-117.
Laparoscopic repair of wide and deep uterine scar dehis- cence after cesarean section. Fertility and Sterility, 89,
 Tulandi, T. and Al-Jaroudi, D. (2004) Interstitial preg- nancy: Results generated from the society of reproductive  Freeman-Walsh, C.B., Fahrig, R., Ganguly, A., Rieke, V. surgeons registry. Obstetrics & Gynecology, 103, 47-50.
and Daniel, B.L. (2008) A hybrid radiography/MRI sys- tem for combining hysterosalpingography and MRI in infertility patients: Initial experience. American Journal  Downey, G.P. and Tuck, S.M. (1994) Spontaneous uterine of Roentgenology, 190, 157-160.
rupture during subsequent pregnancy following non-ex- cision of an interstitial ectopic gestation. British Journal
of Obstetrics & Gynecology, 101, 162-163.
Copyright 2012 SciRes. OJOG
Hippocampal microRNA-132 mediates stress-inducible cognitive deficits through its acetylcholinesterase target G. Shaltiel, M. Hanan, Y. Wolf, S. Barbash, E. Kovalev, S. Shoham & Brain Structure and Function ISSN 1863-2653Brain Struct FunctDOI 10.1007/s00429-011-0376-z Your article is published under the Creative