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Biomedical subjects

R Garry

Publications and source records attributed to R Garry.

At least 37 records · Page 2Linked to original sources
PubMed1998

The validity of continuous automated fluid monitoring during endometrial surgery: luxury or necessity?

Thirty-four consecutive women undergoing endometrial laser ablation, as a treatment of menorrhagia, were recruited to assess the validity of fluid absorption monitoring by a new continuous automated system (AquaSens). The same group of women also had monitoring of fluid absorption carried out by our standard technique of weighing. The intra-class correlation coefficient for the fluid deficit estimated by AquaSens compared to our standard technique of manually weighing the irrigation bags was 0.98 (95% CI 0.96-0.99). Aquasens therefore provides a valid and non-invasive method of continuously monitoring fluid deficit amongst patients undergoing operative hysteroscopy procedures, thereby reducing the risk of unexpected fluid absorption and its potentially fatal sequelae.

Decision Making↗
PubMed1998

Risk of hysterectomy after 1000 consecutive endometrial laser ablations.

OBJECTIVES: To determine the hysterectomy rate after endometrial laser ablation, allowing for variable follow up times, and to evaluate the factors that might predict outcome. DESIGN: Observational cohort study. SETTING: Specialist minimal access gynaecology unit in a district general hospital. METHODS: Data were obtained from case notes, theatre records, and follow up postal questionnaires. The risk of hysterectomy following endometrial laser ablation was assessed using survival curve estimates. Proportional hazards regression analysis was used to identify the predictor(s) of this outcome. RESULTS: A single endometrial laser ablation was carried out on 746 patients (85.4%); 124 patients (14.2%) underwent one repeat procedure and three (0.4%) underwent two repeat ablative procedures. The cumulative rate of return of the postal questionnaires was 87.3% (762/873 patients). Survival curve analysis showed that the overall hysterectomy rate projected over a follow up period of 6.5 years was 21% (95% CI 16%-27%). The age of the patient at endometrial ablation, uterine cavity length, operative time, volume of fluid absorbed, the presence or absence of dysmenorrhoea, premenstrual syndrome and the method of endometrial preparation prior to surgery did not contribute significantly to the regression model. Having a repeat endometrial ablation procedure increased the risk of having a subsequent hysterectomy (RR = 2.93; 95% CI 1.59-5.40; P = 0.0015), whereas the presence of intrauterine pathology (eg, polyps, fibroids and uterine shape abnormalities) decreased the risk of this outcome (RR = 0.26; 95% CI 0.08-0.86; P = 0.0082) after adjustment for confounding due to patient's age and dysmenorrhoea prior to surgery. CONCLUSIONS: Endometrial laser ablation is a safe and effective treatment for menstrual dysfunction. Repeat ablative procedures significantly increased, and the presence of intrauterine pathology decreased, the risk of subsequent hysterectomy.

Adult↗
PubMed1997

Comparison of hysterectomy techniques and cost-benefit analysis.

There are an increasing number of approaches to the surgical removal of the uterus; each of these has clinical advantages and disadvantages. This paper outlines the various forms of laparoscopic hysterectomy currently undertaken and attempts to compare outcome measures and complications with these new approaches. In general laparoscopically-assisted vaginal hysterectomy appears to be associated with longer operating time but less post-operative pain and a shorter convalescent period than both abdominal and vaginal hysterectomy. Economic evaluation is dependent on local factors and upon the type of technique adopted. The use of disposable instrumentation profoundly influences the costs. Laparoscopically-assisted vaginal hysterectomy can be performed for similar or less total costs than conventional surgery providing techniques using re-usable equipment are employed. The place of the laparoscope in facilitating hysterectomy is not yet defined. Techniques are continuing to evolve. The debate now appears to be how laparoscopic and vaginal surgical skills can be best combined to ensure the best possible patient outcome.

Cost-Benefit Analysis↗
PubMed1996

The Depth of the Pneumoperitoneum Determines the Safety of Primary Cannula Insertion

We assessed the anterior-to-posterior depth of pneumoperitoneum at various volumes and pressures, and the actual depth when a standard force was applied to the primary cannula in the umbilicus (equivalent to the normal force used). A 5-mm laparoscope was inserted through a suprapubic port and a depth gauge through the 10-mm intraumbilical port. All gas was initially removed from the abdomen, and the depth of the pneumoperitoneum was measured, with and without the standard force applied to the umbilical port, at incremental volumes and pressures up to 25 mm Hg. Our data strongly suggest that a 2- to 3-L pneumoperitoneum is inadequate in most cases, as the anterior abdominal wall will lie directly against bowel or omentum as soon as any force is applied to the umbilical port. The data also suggest that the pneumoperitoneum should be pressure limited and not volume limited. The pressure should be set at 25 mm Hg, as this gives an adequate pneumoperitoneum depth when the primary cannula is inserted, and hence a greater margin of safety.

Journal Article↗
PubMed1996

Patient Satisfaction with Laparoscopic-Assisted Removal of Large Myomas

The main indications for laparoscopic myomectomy in 10 women (mean age 39.8 yrs) were symptomatic pelvic mass (9), menorrhagia (6), dyspareunia (5), dysmenorrhea (2), and infertility (2). All patients had one or more fibroids larger than 5 cm removed, and in seven the myomata were larger than 10 cm. The mean fibroid mass was 394.7 g (range 130-675 g), and extensive morcellation was required in all women. The mean length of surgery was 153 minutes and hospital stay 3 to 4 days. Overall recovery was excellent in seven and good in three patients. The mean return to normal activity and work was 5.3 weeks (mode 3.0 wks, median 4.5 wks). All women reported improvement in their symptoms as follows: symptomatic mass (9), gone in six and smaller in three; menorrhagia (6), lighter in five and unchanged in one; dyspareunia (5), gone in four and less in 1; dysmenorrhea (2) gone and less in one each. Of the three women trying to conceive since the procedure, two were successful. The mean scar length was 4.9 cm (range 1-6 cm), reported by five women as expected, by four as shorter, and one as longer than expected, but all the patients were satisfied with the scars.

Journal Article↗
PubMed1996

A comparison of goserelin and danazol as endometrial thinning agents prior to endometrial laser ablation.

OBJECTIVE: To compare the effectiveness of goserelin and danazol prior to endometrial laser ablation and assess different dosage regimens. DESIGN: A prospective open randomised trial. SETTING: Specialist unit in minimal access gynaecological surgery in a district general hospital. PARTICIPANTS: One hundred and sixty premenopausal women with dysfunctional uterine bleeding. INTERVENTIONS: Randomisation into four groups receiving either one or two injections of goserelin acetate (3.6 mg subcutaneously) or 28 or 56 days of danazol (four 200 mg tablets daily), followed by endometrial laser ablation. MAIN OUTCOME MEASURES: Endometrial thickness pretreatment and, immediately prior to endometrial laser ablation, assessed by vaginal ultrasound and full thickness endometrial biopsy; appearance of the endometrium at surgery; duration of the operation; the amount of fluid absorbed during surgery; and the clinical outcome at 24 weeks after surgery. RESULTS: The two drugs were equally effective in thinning the endometrium. Compared with danazol, goserelin was better tolerated and resulted in a more satisfactory endometrial appearance at hysteroscopy, a greater reduction in cavity length (0.5 cm compared with 0.3 cm, P = 0.002), a shorter operation (16.4 min compared with 21.6 min, P < 0.001), less fluid absorption (0 ml compared with 200 ml, P = 0.001), and a higher rate of amenorrhoea or oligoamenorrhoea (77% compared with 54%, P < 0.001) at the six month check. The administration of goserelin for 8 weeks compared with 4 weeks produced greater thinning of the endometrium on ultrasound and on histological examination, a greater reduction in cavity length on ultrasound and an increase in reported vasomotor symptoms. In both treatment regimens, 95% of women reported a satisfactory reduction in menstrual flow at the six month check. CONCLUSIONS: Goserelin appears to be more effective and better tolerated than danazol for treatment prior to endometrial laser ablation. Eight weeks treatment with goserelin resulted in better operating conditions and more vasomotor side effect, compared with four weeks treatment, although there was no difference in clinical outcome.

Adult↗
PubMed1995

Six hundred endometrial laser ablations.

OBJECTIVE: To report the effectiveness and safety of endometrial laser ablation in the treatment of menorrhagia, as determined by detailed follow-up of 600 operations for at least 6 months. METHODS: Operative data from 600 endometrial laser ablations performed on 524 women were collected. Five hundred one (96%) of these women were followed with consultations and questionnaires. The mean duration of follow-up was 15 months (range 6-42). RESULTS: No major operative morbidity occurred. There were no cases of primary or secondary hemorrhage, uterine perforations with the operating instrument, or immediate laparotomy. A successful outcome was reported by 83.4% of patients. A second endometrial laser ablation was required in 14.3% of the women. Success increased with increasing age and low fluid absorption. Cavity length, operation time, duration of follow-up, and whether it was a first or second procedure were not associated with any difference in the success rate, although the hysterectomy rate tended to rise with increasing length of follow-up. CONCLUSION: This study, the largest one published from a single institution, with a mean follow-up duration of 15 months, confirms that endometrial laser ablation is a safe and effective treatment for dysfunctional uterine bleeding.

Absorption↗
PubMed1995

Good practice with endometrial ablation.

OBJECTIVE: To provide clear guidelines for the safe and effective performance of endometrial ablation. DATA SOURCES: Representatives of American, Australian, British, and Canadian hysteroscopists were brought together to produce a consensus document of good practice in endometrial ablation. METHODS OF STUDY SELECTION: The guidelines were produced after researching the literature, combining the extensive experience of the group, and debating the relevant issues. CONCLUSIONS: Endometrial ablation is a new procedure. Correct patient selection is essential in producing good results. Patients must be counseled carefully about the advantages, disadvantages, and potential complications of this approach to the management of menstrual disorders. The main indication for endometrial ablation is heavy menstrual loss in the absence of organic disease. Excessive uterine size, the presence of active pelvic infection, and evidence of malignant and premalignant endometrium are absolute contraindications. Ablation can be produced by electrosurgical resection, rollerball or rollerbarrel ablation and Nd-YAG laser ablation. Severe complications can occur, and techniques should be adopted to avoid uterine perforation, hemorrhage, and excessive fluid absorption. In skilled hands, endometrial ablation can be a safe and effective treatment for menorrhagia.

Anesthesia↗
PubMed1995

Endometrial laser ablation.

With good techniques endometrial laser ablation can be a safe and effective treatment for dysfunctional uterine bleeding. For effective intrauterine surgery it is important to control the intrauterine environment during the procedure to ensure safe operating conditions. This can best be achieved by using a continuous flow hysteroscope and pressure-controlled fluid infusion pump. The laser energy should be applied with a direct dragging technique to produce a series of parallel furrows. Safe ablation will be achieved if the three golden rules are followed and the laser is activated only when the tip of the fibre is visible, only when it is being drawn towards the operator and only when the fibre is being moved across the endometrial surface. With a high power Nd: YAG laser at 80 W power, a treatment time of around 20 min should be regularly achieved. This approach can control menstrual flow in 90% of cases and result in an overall satisfactory outcome in around 85% of cases. Improved patient selection may further improve these results. These satisfactory results can be achieved with minimum morbidity but the potential for serious complications still exists so these techniques should not be undertaken without adequate training and good equipment.

Endometrium↗
PubMed1995

Initial experience with laparoscopic-assisted Doderlein hysterectomy.

OBJECTIVE: To assess the outcome of a modified laparoscopic-assisted Doderlein hysterectomy. DEFINE: A prospective clinical study. SETTING: Women's Endoscopic Laser Foundation, South Cleveland Hospital, Middlesbrough, Cleveland. SUBJECTS: Twenty consecutive women with indications for hysterectomy and unsuitable for vaginal approach. INTERVENTION: Laparoscopic-assisted Doderlein hysterectomy with modification to make the technique cost effective. MAIN OUTCOME MEASURES: Operative time, uterine weight, blood loss, hospital stay, intra-operative complications and post-operative complications. RESULTS: The median operative time was 93 minutes, the uterine weight was 168 g, blood loss minimal. The median hospital stay was three days. There were no intra-operative complications and minimal post-operative complications. CONCLUSIONS: The modified laparoscopic-assisted Doderlein hysterectomy is a safe, rapid procedure which allows the patient to achieve all the benefits of laparoscopic surgery with simple and inexpensive laparoscopic and vaginal techniques.

Adult↗
PubMed1995

Techniques of partial hysterectomy: an overview.

With the advent of endometrial ablation and resection, and the laparoscopic techniques for hysterectomy, there has been renewed interest in subtotal or partial hysterectomy. A number of unsubstantiated claims have been made for these new techniques and these are critically reviewed. There appears to be no reason to advocate a change from total hysterectomy to partial hysterectomy on the basis of the currently available evidence.

Cervix Uteri↗