RESULTS: Gravity flushing (1â2 liters UW) produced clear vena cava re- turn. Gonadal vessel ... Target cyclosporin trough levels (150 ng/ml) achieved with 6.5 ...
This data can help physicians determine which patients are at greatest risk for the development of post-myomectomy intrauterine adhesions and may need further evaluation and treatment. Supported by: None. P-341 A COST-EFFECTIVENESS ANALYSIS OF ADHESION BARRIERS IN PREVENTING SMALL BOWEL OBSTRUCTION AFTER TOTAL ABDOMINAL HYSTERECTOMY. R. Alvero, S. Wang, D. Smith. Obstetrics and Gynecology, University of Colorado Health Sciences Center, Aurora, CO. OBJECTIVE: To assess the cost-effectiveness of hyaluronic acid and carboxymethylcellulose in total abdominal hysterectomy in preventing small bowel obstruction after total abdominal hysterectomy. DESIGN: A cost-effectiveness model of the additional financial burden per surgery free years using a health system perspective. MATERIALS AND METHODS: Data pertaining to hospital admissions for small bowel obstruction was obtained from the Nationwide Inpatient Sample (NIS), a data subset of the Healthcare Cost and Utilization Project (HCUP). The NIS is an all-payer inpatient care database, containing data from 1004 hospitals located in 37 states. The 2004 database, which comprises over 90% of all hospital discharges in the United States, was used. Mean charges were used and discounted at 5% per year to estimate current real costs. A decision tree model was created using the TreeAge Health Care module software (TreeAge, Inc, Williamstown, MA). Based on the available literature, an assumption was made that adhesion reduction adjuvants reduce small bowel obstruction by approximately 50%. Sensitivity analysis was performed in the model to allow a reduction range of 20%-70%. RESULTS: The incremental cost effectiveness ratio for the treatment arm of the model (hyaluronic acid þ carboxymethylcellulose) was $95.40 and was dominated by the non treatment arm of the model. This dominance was found at the entire range of small bowel obstruction proportions. CONCLUSIONS: Strictly, the non treatment arm of the decision tree was dominant over the treatment arm. Nevertheless, the incremental cost of using the film was so low that achieving a measurable reduction in small bowel obstruction seems to merit the use of the the adhesion prevention adjuvant to reduce the possibility of such a severe adverse outcome. Surgeons should consider the possibility of post-operative morbidity in their decision to use adhesion barriers. While there is an increase in cost per case, the potential to reduce serious morbidity probably supports the use of these agents in conjunction with good surgical technique. Supported by: None. P-342 A STUDY ABOUT THE TREATMENT OUTCOME OF ENDOMETRIAL HYPERPLASIA BY LETROZOLE AS A PRIMARY THERAPY IN YOUNG WOMEN. H. Li, X. Chen, J. Qiao. Gynecology and Obstetrics, University Hospital, Beijing, China; Gynecology and Obstetrics, University Hospital, Beijing, China; Gynecology and Obstetrics, University Hospital, Beijing, China. OBJECTIVE: To study the treatment outcome of endometrial hyperplasia with or without atypia by letrozole as a primary therapy in young women. MATERIALS AND METHODS: Methods: Five premenopausal women with infertility were diagnosed as endometrial hyperplasia. They were administered 2.5 mg letrozole daily for 3 months. Biopsy was repeated at the end of 3-month therapy. Blood sampling was performed every 1 month for measurement of serum estradiol and progesterone. RESULTS: Dilatation and curettage of the endometrium at the end of therapy in all patients revealed no evidence of endometrial hyperplasia or atypia. Low serum level of estradiol was found in all patients. Four women with secondary amenorrhea had at least one menstrual period. CONCLUSIONS: Endometrial hyperplasia with or without atypia may be treated successfully with letrozole alone as the primary therapy in premenopausal women. More experience will need to be reported before it can be accepted as an alternative medical management of endometrial hyperplasia. Supported by: None. P-343 CONSERVATIVE TREATMENT OF UTERINE ADENOMYOSIS IN THE INFERTILE WOMEN WITH COMBINED PREOPERATIVE GONADOTROPIN-RELEASING HORMONE AGONIST THERAPY
FERTILITY & STERILITYÒ
AND CYTOREDUCTIVE SURGERY. C.-S. Shiau, C.-C. Hsieh, M.-Y. Chang, C.-L. Hsieh, T.-T. Hsieh. Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Taipei, Taiwan. OBJECTIVE: To evaluate the short-term reproductive performance and the reduction of the associated symptoms of a small series of infertile women who underwent combined cytoreductive surgery and a preoperative fourcourse regimen of gonadotropin- releasing hormone agonist therapy for uterine adenomyomas. DESIGN: There is no agreement on the most appropriate therapeutic methods to manage uterine adenomyosis with problem of infertility or other associated symptoms. The reproductive performance and the reduction of the associated symptoms of women with uterine adenomyosis were evaluated after combined therapy in this prospective, observational study. MATERIALS AND METHODS: Twenty-four infertile and symptomatic women with transvaginal sonographically diagnosed adenomyomas had combined (cytoreductive surgery and a preoperative four-course regimen of gonadotropin- releasing hormone agonist therapy) conservative treatment in the period 1999–2004. The preoperative diagnosis was made with selective given transvaginal sonographic parameters and elevated serum CA-125 level. All patients underwent a microsurgical technique and the procedures included initial vasopressin injection, electrosurgery to perform the myometrial incision, accurate hemostasis by meticulous coagulation, application of an adhesion-prevention barrier. All patients were regularly followed for 34.3 2.8 months after completion of treatment and three patients were lost to follow-up after 1 year. RESULTS: The recovery of the associated symptom was seen in 70% of the cases within 12 months and 50% of the cases within 24 months. Seven (33.3%) of the 21 cases become pregnant after cessation of treatment within 24 months period. The time interval between the completion of therapy and spontaneous pregnancy was 6 to 18 months and average 12.0 3.9 months. Four cases were term pregnancy and two cases were preterm labor at 28 and 32 weeks gestation. All these cases ended up with cesarean section and one case was blighted ovum. CONCLUSIONS: This study indicates that combined cytoreductive surgery and a preoperative four-course regimen of gonadotropin- releasing hormone agonist therapy for adenomyomas is associated with a promising reproductive outcome and a reduction in the associated symptoms. Supported by: Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Taipei, Taiwan, Republic of China.
P-344 PRIMATE UTERUS ALLOGRAFT TRANSPLANTATION. G. Del Priore, S. Schlatt, R. Wagner, J. R. Smith, J. Stega. Obstetrics and Gynecology, NY Downtown Hospital-NY Presbyterian Healthcare, New York, NY; Obstetrics and Gynecology, Hammersmith Hospital, London, United Kingdom. OBJECTIVE: To present uterus allograft transplantation in a primate model. DESIGN: Animal model. MATERIALS AND METHODS: 7 adult female rhesus monkeys (Macaca mulatta, Wt: 6.5–10.9 kg, age: 8–15 yrs) all parous, were used in an IACUC approved protocol for uterus transplant; 4 for uterus retrieval and 3 as recipients. Matching of donors and recipient was performed by blood-typing and MHC. Surgeries included general anesthesia (isoflurane) with intubation. 1 week preoperatively an internal jugular vein catheter was surgically inserted (remote sampling setup with jacket and cable attached to a single line). Prior to transplant surgery a femoral/carotid artery catheter was inserted. Both catheters allowed long and short term monitoring and injection of drugs. Pre-retrieval medications included low dose heparin, cyclosporine and vaginal antibiotics. Midline incision permitted retrieval from renal vessels to inguinal ligaments. Bolus heparin (1 mg/kg) adjusted by ACT (activated clotting time) was given prior to aorta cross-clamp. Retrieved organs were preserved in University of Wisconsin solution (UW) for a maximum of 4– 8 hrs on ice, re-perfused with Ringer Lactate and anastomosed to the external iliac arteries/veins or the aorta/vena cava. RESULTS: Gravity flushing (1–2 liters UW) produced clear vena cava return. Gonadal vessel ligation improved perfusion efficiency. All 4 specimens could be retrieved (operative time initially 6, then 21 days). Target cyclosporin trough levels (150 ng/ml) achieved with 6.5 mg/kg/day after adjusting doses (range: 5–8 mg/kg) and daily determination of cyclosporine levels and bone marrow activity via blood sampling. CONCLUSIONS: Uterus allograft transplantation is possible in primates. Other large animal pregnancies have been achieved. They may now be possible in non-human primates. Supported by: Cancer & Fertility Society. P-345 PHYSICIAN AND NURSE ACCURACY OF ESTIMATING BLOOD LOSS. S. Tsirkin, D. Gudipudi, R. Wong, N. Montemarano, G. Del Priore, E. Grinfeld. Research, NY Downtown Hospital New York Presbyterian Healthcare, New York, NY. OBJECTIVE: Estimating blood loss (EBL) is an important part of all surgeries. We determined the accuracy of physicians and nurses in estimating blood loss using vaginal and cesarean deliveries. DESIGN: Prospective, questionnaire. MATERIALS AND METHODS: Physicians and nurses were independently interviewed over 3 months to estimate blood loss after each delivery. Each pregnant woman had hemoglobin testing done antenatally and postpartum to determine the exact blood loss during vaginal or cesarean delivery. The actual blood loss was calculated as the difference between hemoglobin levels antenatal and postpartum using the formula: Hb antenatal – Hb postpartum 450 ml, normalized with 1 gm hgb change ¼ 450 ml whole blood adjusted for weight. Hemoglobin testing postpartum was done 12 hrs or more after delivery. ‘‘Correct’’ EBL was defined as being within 25% of the actual blood loss. RESULTS: Blood loss in 134 deliveries as reported by nurses and physicians ranged from 200–1000 ml with mean of 440 ml and 465 ml, respectively. The actual estimated blood loss ranged 90–2160 ml with mean of 846 ml (Hgb change ¼ 1.88 gm/dl 450 ml). When the actual blood loss was over 1000 ml (n ¼ 47, 35% of total deliveries) both the physicians and nurses EBL were only 39% and 36.6% of the actual blood loss, respectively. When the actual blood loss was below 1000 ml (87 deliveries) both the physicians and nurses EBL was 73.6% and 70%, of actual blood loss respectively (P
