Chronic Steroid Administration Research Articles

Management of Morbidity and Mortality in a New Zealand White Rabbit Model of SteroidInduced Osteonecrosis of the Femoral Head.

Steroid-induced osteonecrosis of the femoral head (SONFH) is a condition documented in humans and animals exposed to chronic steroid administration. The rabbit has become a preferred animal model for investigating the pathogenesis and treatment of SONFH due to its shared femoral vascular anatomy with human patients, relative size of the femoral head, and general fecundity. However, morbidity and mortality are frequent during the steroid induction period, prior to surgical manipulation. These problems are poorly reported and inadequately described in the literature. In this study, we report the clinical, gross, and histopathologic findings of New Zealand white (NZW) rabbits undergoing the steroid induction phase of the SONFH model. Severe weight loss (>30%), lipemia, hypercholesterolemia, hyperglycemia, and elevations in ALT and AST were consistent findings across all rabbits, although these changes did not differentiate asymptomatic rabbits from those that became clinically symptomatic or died. Euthanized and spontaneously deceased rabbits exhibited hepatomegaly, hepatic lipidosis/glycogenosis, and hepatocellular necrosis, in addition to a lipid-rich and proteinaceous thoracic effusion. A subset of rabbits developed opportunistic pulmonary infections with Bordetella bronchiseptica and Escherichia coli and small intestine infections with Lawsonia intracellularis superimposed on hepatic and thoracic disease. Together, these findings allowed us to establish a clinical decision-making flowchart that reduced morbidities and mortalities in a subsequent cohort of SONFH rabbits. Recognition of these model-associated morbidities is critical for providing optimal clinical care during the disease induction phase of SONFH.

Lipid Profile Changes Induced by Chronic Administration of Anabolic Androgenic Steroids and Taurine in Rats.

Background and Objectives: Anabolic androgenic steroids (AAS), used as a therapy in various diseases and abused in sports, are atherogenic in supraphysiological administration, altering the plasma lipid profile. Taurine, a conditionally-essential amino acid often used in dietary supplements, was acknowledged to delay the onset and progression of atherogenesis, and to mitigate hyperlipidemia. The aim of the present study was to verify if taurine could prevent the alterations induced by concomitant chronic administration of high doses of AAS nandrolone decanoate (DECA) in rats. Materials and Methods: Thirty-two male Wistar rats, assigned to 4 equal groups, were treated for 12 weeks either with DECA (A group), taurine (T group), both DECA and taurine (AT group) or vehicle (C group). Plasma triglycerides (TG), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), hepatic triglycerides (TGh) and liver non-esterified fatty acids (NEFA) were then determined. Results: DECA elevated TG level in A group vs. control (p = 0.01), an increase prevented by taurine association in AT group (p = 0.04). DECA decreased HDL-C in A group vs. control (p = 0.02), while taurine tended to increase it in AT group. DECA decreased TGh (p = 0.02) in A group vs. control. Taurine decreased TGh in T (p = 0.004) and AT (p < 0.001) groups vs. control and tended to lower NEFA (p = 0.08) in AT group vs. A group. Neither DECA, nor taurine influenced TC and LDL-C levels. Conclusions: Taurine partially prevented the occurrence of DECA negative effects on lipid profile, suggesting a therapeutic potential in several conditions associated with chronic high levels of plasma androgens, such as endocrine disorders or AAS-abuse.

Intraocular Surgery in Behcet's Disease

Behçet’s disease (BD) is a multisystemic vasculitis characterized by multiorgan involvement presenting with recurrent oral and/or genital ulcerations, skin lesions, and uveitis. Ocular involvement often occurs as remitting panuveitis and retinal vasculitis and the visual prognosis is poor if not treated properly. Relapsing uveitis attacks and chronic steroid administration during the treatment period may increase the risk of cataract and glaucoma formation. Also, recurrent uveitis may lead to severe visual compromise due to several posterior segment complications such as vitreous opacification, vitreoretinal interface changes, retinal neovascularization, cystoid macular edema, and optic atrophy. Systemic drugs including steroids, immunosuppressive, and biologic agents usually decrease the severity and frequency of the uveitis. Cataract, glaucoma, and vitreoretinal surgeries in eyes with uveitis may show some difference from the general practice. In this manuscript, approaches in anterior and posterior segment ocular surgeries in BD patients are reviewed.

Administration of anabolic steroid during adolescence induces long-term cardiac hypertrophy and increases susceptibility to ischemia/reperfusion injury in adult Wistar rats

Chronic administration of anabolic androgenic steroids (AAS) in adult rats results in cardiac hypertrophy and increased susceptibility to myocardial ischemia/reperfusion (IR) injury. Molecular analyses demonstrated that hyperactivation of type 1 angiotensin II (AT1) receptor mediates cardiac hypertrophy induced by AAS and also induces down-regulation of myocardial ATP-sensitive potassium channel (KATP), resulting in loss of exercise-induced cardioprotection. Exposure to AAS during adolescence promoted long-term cardiovascular dysfunctions, such as dysautonomia. We tested the hypothesis that chronic AAS exposure in the pre/pubertal phase increases the susceptibility to myocardial ischemia/reperfusion (IR) injury in adult rats. Male Wistar rats (26day old) were treated with vehicle (Control, n=12) or testosterone propionate (TP) (AAS, 5mgkg−1 n=12) 5 times/week during 5 weeks. At the end of AAS exposure, rats underwent 23days of washout period and were submitted to euthanasia. Langendorff-perfused hearts were submitted to IR injury and evaluated for mechanical dysfunctions and infarct size. Molecular analysis was performed by mRNA levels of α-myosin heavy chain (MHC), βMHC and brain-derived natriuretic peptide (BNP), ryanodine receptor (RyR2) and sarcoplasmic reticulum calcium ATPase 2a (SERCA2a) by quantitative RT-PCR (qRT-PCR). The expression of AT1 receptor and KATP channel subunits (Kir6.1 and SURa) was analyzed by qRT-PCR and Western Blot. NADPH oxidase (Nox)-related reactive oxygen species generation was assessed by spectrofluorimetry. The expression of antioxidant enzymes was measured by qRT-PCR in order to address a potential role of redox unbalance. AAS exposure promoted long-term cardiac hypertrophy characterized by increased expression of βMHC and βMHC/αMHC ratio. Baseline derivative of pressure (dP/dt) was impaired by AAS exposure. Postischemic recovery of mechanical properties was impaired (decreased left ventricle [LV] developed pressure and maximal dP/dt; increased LV end-diastolic pressure and minimal dP/dt) and infarct size was larger in the AAS group. Catalase mRNA expression was significantly decreased in the AAS group. In conclusion, chronic administration of AAS during adolescence promoted long-term pathological cardiac hypertrophy and persistent increase in the susceptibility to myocardial IR injury possible due to disturbances on catalase expression.

Steroid-induced Glaucoma: An Avoidable Irreversible Blindness

ABSTRACT Steroids are a group of anti-inflammatory drugs, commonly used to treat ocular and systemic conditions. Unmonitored use of steroids especially in eye drop formulations is common in situations when it is easily available over-the-counter, resulting in undesirable side effects. Among the ocular side effects, cataract and glaucoma are common. Steroid-induced ocular hypertension was reported in 1950, when long-term use of systemic steroid was shown to increase the intraocular pressure (IOP). Chronic administration of steroids in any form with raised IOP can cause optic neuropathy resulting in steroid-induced glaucoma. This review describes the pathophysiology and epidemio­logy of steroid-induced glaucoma, recognition of side effects, and principles of management. The purpose is to familiarize all clinicians with the potential dangers of administering steroids without monitoring the eye and the dangers of irreversible blindness in some instances of habitual self-prescription by patients. How to cite this article Phulke S, Kaushik S, Kaur S, Pandav SS. Steroid-induced Glaucoma: An Avoidable Irreversible Blindness. J Curr Glaucoma Pract 2017;11(2):67-72.

P117 The extent of immunosuppression from systemic steroid bursts in inner-city asthmatic children - an update

Systemic corticosteroids are mainstay treatment for acute asthma exacerbations. The effect of chronic administration of systemic steroids in patients with autoimmune disorders has been reported. However, the quantified severity and extent of immunosuppression in asthmatic children receiving frequent systemic steroids bursts has not been reported.

Impact of Angiotensin-II receptor blockers on vasogenic edema in glioblastoma patients.

Glioblastoma patients often require chronic administration of steroids due to peri-tumoral edema. Preliminary studies showed that treatment with Angiotensin-II Receptor Blockers (ARBs) for high blood pressure might be associated with reduced peri-tumoral edema. In this study, we aim to radiologically assess the effect of ARBs on peri-tumoral edema. We conducted a cross-sectional survey on patients with newly diagnosed GBM. Patients treated with ARBs for high blood pressure were paired to non ARB-treated patients based on similar age, tumor location and tumor size. Patients taking steroids at the time of pre-operative Magnetic Resonance Imaging were excluded from the study. In each pair of patients, we compared the volumes of peri-tumoral hyper T2-Fluid Attenuated Inversion Recovery (FLAIR) signal and the Apparent Diffusion Coefficient (ADC) in the same area. Eleven (11) ARB-treated patients were selected and paired to 11 non ARB-treated controls. Volumes of peri-tumoral hyper T2-FLAIR signal were significantly lower in the ARB-treated group than in the non ARB-treated group (p = 0.02). Additionally, peri-tumoral ADCs were also significantly lower in the treated group (p = 0.02), suggesting that the peri-tumoral area in this group had less edematous features. These results suggest that ARBs may reduce the volume of peri-tumoral hyper T2-FLAIR signal by decreasing edema.

Impact of omalizumab therapy on medication requirements for chronic rhinosinusitis.

Omalizumab is indicated for treatment of patients with moderate to severe allergic asthma. Previous studies have shown 70% of these patients also have chronic rhinosinusitis (CRS). The present series examines the impact of omalizumab on medication use for CRS in a cohort of asthmatic CRS patients who received this therapy. The sample included 25 patients with adequate prescription data preinitiation and postinitiation of therapy. Data was available for a full 12 months both preinitiation and postinitiation of therapy in 20 of 25 patients and for 4 to 8 months in the remaining 5 of 25. Average antibiotic use (# of unique prescriptions per month) and systemic steroid dose (mg/month) were tabulated for each patient and compared before and after initiation of therapy. Mean antibiotic prescriptions/month decreased by 37%, and this was statistically significant (p = 0.013). Antibiotic use decreased in 15 of 25 (60%), was the same in 7 of 25 (28%), and increased in 3 of 25 (12%) patients. Chronic steroid administration was required in 19 of 25 patients, and dosing was highly variable. Mean monthly steroid dose decreased substantially in 8 of 19 (42%) patients, with reduction ranging from 40% to 100% from pretreatment levels. A modest decrease of 17% to 30% was observed in 4 of 19 (21%) patients. Steroid use was essentially unchanged in 4 of 19 (21%), but dramatically increased (71% to 366% above pretreatment dose) in 3 of 19 (15%) patients. Omalizumab therapy is associated with a decrease in overall antibiotic use for CRS. A subset of patients also experience significant reduction in steroid dependence. Further study is necessary to determine factors predictive of response.

NIMG-44IMPACT OF ANGIOTENSIN-II RECEPTOR BLOCKERS ON VASOGENIC EDEMA IN GLIOBLASTOMA PATIENTS

BACKGROUND: A significant morbidity in glioblastoma (GBM) patients is related to peri-tumoral edema, which requires chronic administration of steroids. Preliminary studies have shown that treatment with Angiotensin-II receptor blockers (ARBs) for high blood pressure might be associated with reduced peri-tumoral edema. Our goal in this study was to radiologically assess the effect of ARBs on peri-tumoral vasogenic edema. METHODS: We conducted a cross-sectional survey on patients with newly diagnosed GBM. Patients treated with ARBs for high blood pressure were paired to non ARB-treated patients, based on similar age, tumor location and longest diameter. Patients taking steroids at the time of their pre-operative Magnetic Resonance Imaging were not eligible for this study. In each pair of patients, we compared the volumes of peri-tumoral hyper T2 FLAIR signal and the apparent diffusion coefficient (ADC) selected in the same area. RESULTS: Eleven (11) patients treated with ARBs were selected and paired to 11 non ARB-treated controls. Volumes of peri-tumoral hyper T2 FLAIR signal were significantly lower in the ARB-treated group than in the non ARB-treated group (p = 0.02). Peri-tumoral ADCs were also significantly lower in the treated group (p = 0.02), suggesting that brain surrounding the tumor had less edematous characteristics when patients were treated with ARBs. CONCLUSION: All together, these results suggest that ARBs could reduce the volume of peri-tumoral hyper T2 FLAIR signal by decreasing vasogenic edema.

Outcomes for extremely premature infants.

Premature birth is a significant cause of infant and child morbidity and mortality. In the United States, the premature birth rate, which had steadily increased during the 1990s and early 2000s, has decreased annually for 7 years and is now approximately 11.39%. Human viability, defined as gestational age at which the chance of survival is 50%, is currently approximately 23 to 24 weeks in developed countries. Infant girls, on average, have better outcomes than infant boys. A relatively uncomplicated course in the intensive care nursery for an extremely premature infant results in a discharge date close to the prenatal estimated date of confinement. Despite technological advances and efforts of child health experts during the last generation, the extremely premature infant (less than 28 weeks gestation) and extremely low birth weight infant (<1000 g) remain at high risk for death and disability with 30% to 50% mortality and, in survivors, at least 20% to 50% risk of morbidity. The introduction of continuous positive airway pressure, mechanical ventilation, and exogenous surfactant increased survival and spurred the development of neonatal intensive care in the 1970s through the early 1990s. Routine administration of antenatal steroids during premature labor improved neonatal mortality and morbidity in the late 1990s. The recognition that chronic postnatal administration of steroids to infants should be avoided may have improved outcomes in the early 2000s. Evidence from recent trials attempting to define the appropriate target for oxygen saturation in preterm infants suggests arterial oxygen saturation between 91% and 95% (compared with 85%-89%) avoids excess mortality; however, final analyses of data from these trials have not been published, so definitive recommendations are still pending. The development of neonatal neurocritical intensive care units may improve neurocognitive outcomes in this high-risk group. Long-term follow-up to detect and address developmental, learning, behavioral, and social problems is critical for children born at these early gestational ages.The striking similarities in response to extreme prematurity in the lung and brain imply that agents and techniques that benefit one organ are likely to also benefit the other. Finally, because therapy and supportive care continue to change, the outcomes of extremely low birth weight infants are ever evolving. Efforts to minimize injury, preserve growth, and identify interventions focused on antioxidant and anti-inflammatory pathways are now being evaluated. Thus, treating and preventing long-term deficits must be developed in the context of a "moving target."

Anterior and posterior segment changes in rat eyes with chronic steroid administration and their responsiveness to antiglaucoma drugs

Steroid-induced ocular hypertension (SIOH) is associated with topical and systemic use of steroids. However, SIOH-associated anterior and posterior segment morphological changes in rats have not been described widely. Here we describe the pattern of intraocular pressure (IOP) changes, quantitative assessment of trabecular meshwork (TM) and retinal morphological changes and changes in retinal redox status in response to chronic dexamethasone treatment in rats. We also evaluated the responsiveness of steroid-pretreated rat eyes to 5 different classes of antiglaucoma drugs that act by different mechanisms. Up to 80% of dexamethasone treated animals achieved significant and sustained IOP elevation. TM thickness was significantly increased and number of TM cells was significantly reduced in SIOH rats compared to the vehicle-treated rats. Quantitative assessment of retinal morphology showed significantly reduced thickness of ganglion cell layer (GCL) and inner retina (IR) in SIOH rats compared to vehicle-treated rats. Estimation of retinal antioxidants including catalase, superoxide dismutase and glutathione showed significantly increased retinal oxidative stress in SIOH animals. Furthermore, steroid-treated eyes showed significant IOP lowering in response to treatment with 5 different drug classes. This indicated the ability of SIOH eyes to respond to drugs acting by different mechanisms. In conclusion, SIOH was associated with significant morphological changes in TM and retina and retinal redox status. Additionally, SIOH eyes also showed IOP lowering in response to drugs that act by different mechanisms of action. Hence, SIOH rats appear to be an inexpensive and noninvasive model for studying the experimental antiglaucoma drugs for IOP lowering and neuroprotective effects.

Idiopathic scaphoid avascular necrosis in a patient with hypohidrotic congenital ectodermal dysplasia

Hypohidrotic ectodermal dysplasia (HED), also called Christ–Siemens–Touraine (CST) syndrome, is a rare genetic syndrome that affects structures of ectodermal origin, such as the nails, teeth, hair, sweat glands, and skin. Deficiency or absence of these anatomical structures can result in hypotrichosis, hypodontia, hypohidrosis, or anhidrosis. Most cases show X-linked inheritance associated with mutations in the ectodysplasin (EDA) gene, although autosomal dominant or recessive inheritance patterns have also been observed. Avascular necrosis of the scaphoid bone is common after a fracture and can also be associated with systemic disease or chronic steroid administration, while idiopathic avascular necrosis of the scaphoid is very rare. This report presents a patient with HED who developed idiopathic avascular necrosis of the scaphoid and discusses the potential association between the two.

National patient dose survey in dental CBCT and elaboration of national DRLs

National patient dose survey in dental CBCT and elaboration of national DRLs

Relationship between 22-kHz calls and testosterone in male rats

Ultrasonic calls in rats induced by the presence of a predator, referred to as “22-kHz calls,” are mainly emitted by socially dominant male rats. Testosterone levels are closely related to social dominance in male rats. In the present study, we investigated the relationship between the emission of stress-induced 22-kHz calls and circulating testosterone levels in male rats, using a combination of surgery (castration or sham operation) and chronic steroid administration (testosterone or cholesterol) to modify circulating testosterone levels. We also assessed the effects of androgen and/or estrogen receptor antagonists on the emission of 22-kHz calls in male rats. An air puff stimulus, known to reliably induce 22-kHz calls in rats, was used as a stressor. Castrated rats with cholesterol implants exhibited significantly fewer 22-kHz calls than rats that had received a sham operation and cholesterol implants, and there was no significant difference between castrated rats with testosterone implants and rats that had received a sham operation and cholesterol implants. Only male rats pretreated with a binary mixture of androgen and estrogen antagonists exhibited significantly fewer 22-kHz calls than controls. These results show that testosterone in male rats has a positive effect on the emission of stress-induced 22-kHz calls, and the calls may be regulated by the activation of both androgen and estrogen receptors.

Idiopathic intracranial hypertension: A possible complication in the natural history of advanced prostate cancer

Idiopathic intracranial hypertension is a variety of intracranial hypertension that is extremely rare in men. Obesity and hypogonadism are the most important predictive factors. Etiological hypotheses include increased central venous pressure, and various hormonal and metabolic changes commonly found in obese patients. We described the case of an obese man with prostate cancer who showed a consistent bodyweight increase during treatment with taxanes and prednisone. He was hospitalized because of a severe loss of vision as a consequence of idiopathic intracranial hypertension. A complete symptom remission was obtained after 3 weeks of anti-edema therapies (steroids, acetazolamide). Castration-resistant prostate cancer is a risk factor for idiopathic intracranial hypertension. Long-term androgen deprivation therapy, bodyweight increase, and fluid retention during chronic steroid administration and taxane chemotherapy might favor the disease onset. This severe complication has a good outcome, and should be suspected in the presence of symptoms and signs of intracranial hypertension.

Influence of chronic administration of anabolic androgenic steroids and taurine on haemostasis profile in rats

Anabolic androgenic steroids (AAS) are synthetic derivatives of testosterone with thrombogenic potential in high doses and long-term administration. Taurine, a widely distributed amino-sulfonic acid, is known for its beneficial effects in hypercoagulable states. In order to assess the impact of chronic administration of high doses of AAS and taurine upon haemostasis process in rats, 40 male Wistar rats were divided into four equal groups: control group (group C) - no treatment; androgen group (group A) - received 10 mg/kg per week of nandrolone decanoate (DECA); taurine (group T) - received oral supplementation of 2% taurine in drinking water; androgen and taurine group (group AT) - concomitant administration of DECA and taurine. After 12 weeks, blood samples were collected and haemostasis parameters were assessed with the thrombelastographic (TEG) analysis system: reaction time, clot kinetics (K, α), final clot strength, coagulation index and the clot lysis (Ly30). Nandrolone significantly decreased reaction time in group A compared with control (P<0.001), whereas taurine significantly increase reaction time (P=0.01), and this effect was maintained in group AT compared with group A (P=0.009). Similar differences between groups have been recorded for the clot kinetics parameters K, α. The final clot strength and coagulation index were significantly increased in group A versus group C (P=0.04, respectively P<0.001), but not in group AT versus group C (P>0.05). There were no differences in clot lysis, as shown by Ly30. Nandrolone produces an accelerated clot development and an increased clot firmness in Wistar rats. Taurine association ensures a protective effect against this hypercoagulable state, partially restoring the altered parameters of the coagulation profile.

Effect of chronic administration of anabolic androgenic steroids and taurine on platelet aggregation in rats

Effect of chronic administration of anabolic androgenic steroids and taurine on platelet aggregation in rats

Medical influences, surgical outcomes: Role of common medications on the risk of perforation from untreated diverticular disease

Numerous drugs, largely used in the wards or at home, have a significant influence on patients with untreated diverticular disease. The consequences can be disastrous, may require an emergency operation, postoperative intensive care, and overall influence the patient's length of stay and the final outcomes. Bearing these considerations in mind the routine or chronic administration of pain-killers, steroids and non-steroidal anti-inflammatory should be balanced in patients with known diverticular disease as it normally happens with other conditions potentially affected by these drugs (i.e., peptic ulcer disease or chronic obstructive pulmonary disease). This is even more important in the old and frail patient where an eventual surgical treatment may not always be possible.

Authors’ response

We appreciated the interesting comments of Uccella et al. about our paper [ [1] Ceccaroni M. Berretta R. Malzoni M. et al. Vaginal cuff dehiscence after hysterectomy: a multicenter retrospective study. Eur J Obstet Gynecol Reprod Biol. 2011; 158: 308-313 Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar ]. As previously stated, different aspects can play a role in the genesis of vaginal cuff dehiscence, such as vault infections, wound hematoma, resumption of sexual activity before complete healing, advanced age, previous radiation therapy, chronic steroid administration and trauma [ [2] Iaco P.D. Ceccaroni M. Alboni C. et al. Transvaginal evisceration after hysterectomy: is vaginal cuff closure associated with a reduced risk?. Eur J Obstet Gynecol Reprod Biol. 2006; 125: 134-138 Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar ]. Uccella et al. underlined that the route by which colporrhaphy is performed represents an important factor influencing the risk of dehiscence. In a retrospective review, the authors reported that laparoscopic and robotic vault sutures showed a higher risk of dehiscence when compared with the trans-vaginal approach [ [3] Uccella S. Ghezzi F. Mariani A. et al. Vaginal cuff closure after minimally invasive hysterectomy: our experience and systematic review of the literature. Am J Obstet Gynecol. 2011; (March) [Epub ahead of print] Google Scholar ]. Moreover, in this series, the vaginal route not only seemed to allow better results but also was shown to be an easier procedure compared with laparoscopic colporrhaphy. Deep rectal and parametrial infiltrating endometriosis with monolateral pudendal nerve involvement: case report and laparoscopic nerve-sparing approachEuropean Journal of Obstetrics and Gynecology and Reproductive BiologyVol. 153Issue 2PreviewWe report a case of a 32-year-old woman, referred to our unit for pelvic pain syndrome with severe constipation, dyschezia, dysmenorrhea and ano-genital pain refractory to hormonal and opioid therapy. The patient reported catamenial irradiation of pelvic pain to the right ano-genital region and to her right leg, with impaired motility and sensitivity during pain peaks. Pain was evaluated using a visual analogue scale (VAS) [1], which showed unbearable dyschezia (VAS score = 10), severe dysmenorrhea (VAS score = 8) and right pudendal neuralgia (VAS score = 9). Full-Text PDF Vaginal cuff dehiscence after laparoscopic hysterectomyEuropean Journal of Obstetrics and Gynecology and Reproductive BiologyVol. 161Issue 1PreviewWe read with much attention the very interesting paper by Ceccaroni et al. entitled “Vaginal cuff dehiscence after hysterectomy: a multicenter retrospective study” [1]. The article evaluates different important features of vaginal evisceration after hysterectomy (i.e. time of onset, trigger event, presenting symptoms). Among the other strengths, the article has the merit to present data from a large population (more than 8000 patients), and to stress the difference between the various approaches to hysterectomy, in terms of risk of vaginal cuff dehiscence. Full-Text PDF

Vaginal vault dehiscence with evisceration after total laparoscopic hysterectomy

Vault dehiscence and evisceration of peritoneal contents is a rare complication following total hysterectomy. A 43-yearold lady presented with history of something soft coming out per vaginum. She underwent total laparoscopic hysterectomy 2 months back for 16-week fibroid uterus. The surgery was uneventful, vaginal vault was sutured laparoscopically with no 1 polyglactin, interrupted figure of eight sutures. She was discharged after 48 h with uneventful recovery and subsequently presented with mass protruding per vaginum. Speculum examination showed loops of small bowel protruding in the vagina (Fig. 1). She was hospitalized and scheduled for reduction of the prolapsed bowel with vault repair. On examination under anaesthesia, there was complete dehiscence of the vaginal vault with loops of small bowel protruding through the defect. To maintain the pneumoperitoneum vagina was blocked using a simple vaginal tampon soaked in betadine solution (Fig. 2) [1]. On Laparoscopic evaluation the entire vault was deficient. There were no bowel, bladder or omental adhesions to the vault. The prolapsed ileal loops were seen just at the vault, with healthy pink colour and regular peristalsis. On giving Trendelenburg’s position the reposition was smooth. After confirming that the vault was free of any adhesions, the vault was closed vaginally using interrupted no 1 Polydioxone II sutures (Fig. 3). Patient was discharged on the third post-operative day and is asymptomatic at 6-month follow-up. Vaginal vault dehiscence with evisceration posthysterectomy can occur up to few weeks to even few years after hysterectomy. The commonest organ to eviscerate is small bowel, particularly terminal ileum. Several factors which may contribute to weakness of vaginal apex are poor surgical techniques, post-operative wound haematoma and cuff infection, post-menopausal status, any activity resulting in increased intra-abdominal pressure, early resumption of sexual activity, chronic steroid administration, history of previous radiotherapy in cases of radical hysterectomy [2] and systemic illness like diabetes mellitus and immunecompromised status [3].