Biomedical subjects
Publications and source records attributed to H Grundsell.
A case of prolapse of the small bowel through the vagina after gynaecologic operations is described. This is a very rare complication and up to date only eleven cases have been described. Measures to prevent this complication are discussed.
Nine women suffering from vaginal vault prolapse had an abdominal sacropexy between 1972 and 1983. Marlex mesh was used to anchor the vaginal vault to the promontory of the sacrum and was completely buried retroperitoneally. The women had all had previous attempts at surgical correction. There were no intra- or post-operative complications. No recurrences of vault prolapse occurred during a mean follow-up period of 3.9 years. One woman developed a moderate cystocoele 4 years after sacropexy.
Extensive and/or recurrent condylomata acuminata in 78 women were treated with the CO2 laser. Urethra, clitoris or the anal canal were involved in about one-fourth of the cases. Most were treated as outpatients with the more extensive lesions staged for multiple treatments. After a follow-up period of 6-33 months, 91% of women were free from disease and treatment failures occurred in 9%, some of which may have been new infections. No serological investigations were performed.
One hundred forty patients who underwent laser conization and 220 patients who underwent laser miniconizations were prospectively randomized into two study groups. One treatment group was given antifibrinolytic therapy in the form of tranexamic acid (Cyklokapron, KabiVitrum, Sweden) intraoperatively and for 14 days postoperatively. The other group did not receive antifibrinolytic therapy. In the group of 68 patients with laser conizations who were given antifibrinolytic therapy, no postoperative hemorrhages occurred, whereas there were eight such hemorrhages in 72 conizations (11%) in the untreated patients. This difference is statistically significant (P = .004, Fisher exact test for two proportions). Also, for laser miniconization, the frequency of postoperative hemorrhage was almost halved, from 9.1% in 110 patients not receiving antifibrinolytic therapy to 5.5% in the 110 treated patients. The use of lateral cervical sutures did not reduce the frequency of postoperative hemorrhage at laser conization in the present study.
Three hundred forty-three cases of early invasive carcinoma of the uterine cervix were analyzed. Depth of infiltration and lateral extension of the tumors varied between 0.2 and 9.0 mm and 0.4 and 17.2 mm and were found to be of no prognostic importance. A multivariate statistical analysis revealed several risk factors: an epithelialized portio at diagnosis, suspected or evident tumor invasion in capillary-like spaces, absence of tumor-free margins at conization, and treatment with conization or simple hysterectomy, especially in the presence of the above-mentioned factors. Tumors of a large cell keratinizing type were prognostically favorable. Confluent growth was not associated with increased risk of recurrence or death from recurrence. Cervical biopsies proved to be inadequate as diagnostic material. Recurrences were almost always local and developed late. In absence of risk factors conization is sufficient treatment. In the presence of risk factors treatment should be the same as that performed for frankly invasive Stage IB carcinomas.
Mass cytologic screening for cervical cancer often reveals only mild dysplasia not indicating conization but necessitating continual checkup. Such routine checkups are often insufficient, beside which the patients find them frustrating. Therefore a new method, called miniconization, for treatment of patients with vaginal smears showing mild or moderate dysplasia (cervical intraepithelial neoplasia/CIN/I-II), was developed. With the CO2 laser handpiece a 5-mm-thick disc of the cervix, including the whole transformation zone, was removed. This was followed by endocervical curettage. The advantage of the method over cryosurgery, electrocoagulation, and laser vaporization, for example, is that the tissue specimen as a whole disc including the transformation zone can be sectioned and examined histologically. Another advantage is the decreased risk of postoperative bleeding, which enables ambulant care. One hundred and fifty-one patients have hitherto been treated and carcinoma in situ has been found in 15.2% and microinvasive carcinoma in 1.3% of all these patients in whom vaginal smears showed mild or moderate dysplasia (CIN I-II).
A comparison was made of intraoperative and postoperative complications of laser conization and cold knife conization. Of 428 women hospitalized for cold knife conization, 23.6% had one or more complications; 14.3% had postoperative hemorrhages, 6.8% had infections, and 4.7% suffered from stenosis. Two hundred sixteen women were hospitalized for laser conization; 5.1% of them suffered complications. Postoperative hemorrhages occurred in 2.8% and infections in 2.3%. No case of stenosis occurred. Laser conization as an outpatient procedure was undertaken in 240 women; 4.2% had complications. Postoperative hemorrhages occurred in only 2.5%, infections in 1.3%, and stenosis in 0.8%. Laser conization has the same complication rate as laser vaporization and can be safely performed on an outpatient basis, thereby reducing hospital costs.
Follow-up results by vaginal cytology and colposcopy after laser conization for early cervical neoplasia in 333 patients are reported. 95.7% of all the women were free from disease after 4-24 months. The separate figure for very early invasive carcinoma was 96.4% and for CIN III through CIN I it was 96.6%, 94.9% and 90.6% respectively. The cure rate depended on whether or not the resection margins of the cones were free from epithelial cells with atypia. The highest cure rate, 97.8%, was noted for CIN III with margins free from atypical cells. Out of patients not free from disease, 92.9% were detected at the first follow-up at 4--6 months after conization and represent persistent disease. Laser conization seems to give at least as good cure rates as laser vaporization and has the chief advantage that histopathological evaluation is available both for the whole lesion and the resection of the cones. The procedure can be safely performed on an out-patient basis.
The miniconization by carbon dioxid laser is a non-destructive method for treatment of mild and moderate dysplasia of the uterine cervix permitting an adequate histopathological interpretation of the whole transformation zone. The risk of postoperative haemorrhage is minimal which enables ambulant care. 413 patients have hitherto been treated and we have found carcinoma in situ in 16.7%, micro-invasive carcinoma in 1.2% and invasive carcinoma in 0.25%.
The outcome of 635 pregnancies in 197 women before and after conization is reported. After conization a significant increase in premature deliveries occurred in young women (age 21-25), nulliparae representing the highest risk. The rate of premature deliveries in this age group was 4.4% before conization and 30.6% after conization. No such increase could be found in any other age group. Labor was notably short in non-parous women and in parous women it started with rupture of the membranes significantly more often after conization. In addition, a significant increase in the frequency of cervical stenosis was observed, but this was of clinical significance in only one case. Treatment in the form of prophylactic cerclage did not reduce the incidence of either premature delivery or of late spontaneous abortion.
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In an effort to reduce the complication rate at laparoscopy, especially in patients who have previously undergone laparotomy, the so-called open laparoscopy technique was developed by Hasson and Grimes. Both investigators use minilaparotomy to enter the abdominal cavity. Hasson has developed a special laparoscopic instrument, whereas Grimes uses conventional instrumentation. For 1 year the authors have been using an extremely simple and safe method in performing laparoscopy: After incision of the skin and fascia infraumbilically, the index finger is introduced through these incisions, and the preperitoneal fat and the peritoneum are perforated with the finger, which is also used to explore the area around the incision for adhesions. After insufflation of CO2 through the sleeve, the optics are introduced in the usual manner.
This prospective, randomized study compares, for the first time, measured blood loss at conization and within 24 hours after using either the cold knife technique or the carbon dioxide laser scalpel. One hundred and ten consecutive patients were evaluated. The median blood loss in the laser group of 55 patients was 4.6 milliliters at, and within, 24 hours after operation compared with 30.1 milliliters in the cold knife group of 55 patients. More important, however, is that the corresponding figures for the range of bleeding were 0.4 to 155.4 milliliters and 5.6 to 1,570.9 milliliters, respectively. The incidence rate for bleeding complications requiring surgical intervention was 1.8 per cet for the laser group and 14.6 per cent for the cold knife group. This difference was statistically significant, p less than 0.015--Fischer's exact test. Conization for treatment of premalignant changes of the cervix uteri will probably remain the treatment of choice for some time to come. It is our opinion that, in the future, laser conization will replace cold knife conization.
The attitude of the fetal head was determined in 445 women with breech presentations. Thirty-three women (7.4 per cent) were found to have a fetus with the head in various degrees of hyperextension. Of these 26 were born vaginally and seven by Caesarean section. At follow-up (2 to 4 years) five of the vaginally born infants (22 per cent) had neurological sequelae referable to spinal, supraspinal and cerebellar injuries but all infants born by Caesarean section were normal. The results emphasise the value of an abdominal X-ray examination of all women with breech presentations. Caesarean section is recommended if the fetal head is hyperextended.
The early diagnosis of ovarian carcinoma is as difficult and rare as ever before. Despite the appearance of sophisticated drugs and combinations of these with surgery and radiotherapy the prognosis still remains the same as during the last 30 years, i.e. overall survival between 20 to 30%. This study concerns the impact of prophylactic oophorectomy in Sweden. 4.6% of ovarian carcinoma patients had received pelvic surgery at some time prior to the diagnosis of ovarian cancer and after the age of 40. With the help of statistical data it is estimated that about one hundred out of the approximately thousand women per year who now develop ovarian cancer in Sweden could be saved if prophylactic oophorectomy were practised in our country. Various aspects of prophylactic oophorectomy and its effects are discussed. It is our opinion that every gynaecologist/surgeon should seriously take into consideration and discuss the possibility of prophylactic oophorectomy in the perimenopausal patient before operation. Not to perform prophylactic oophorectomy during pelvic surgery after the menopause seems to us to be an unreasonable practice.
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