Postoperative adhesion prevention with low-dose aspirin: effect through the selective inhibition of thromboxane production

The aim of the present study was to evaluate the efficacy of low-dose versus high-dose aspirin in the prevention of postoperative adhesion formation. Forty New Zealand White rabbits were randomized into three groups: low-dose aspirin (1.7 mg/kg per day for 5 days starting on the day of surgery), high-dose aspirin (28.0 mg/kg per day), and controls. The rabbits underwent a standardized surgical injury on the ovary, uterine horn and abdominal wall on one side at laparotomy. On postoperative day 21, a second-look laparotomy was performed for the evaluation of postoperative adhesions. In five animals in each group, peritoneal fluid samples were collected at initial surgery, then through an additional 2 cm incision performed on postoperative day 3, and at second-look laparotomy. The peritoneal concentrations of thromboxane B2 and 6-keto-prostaglandin F1alpha (the stable hydrolysis product of prostacyclin) were measured by radioimmunoassay. At second-look laparotomy, the adhesion formation rate was 46% in the low-dose aspirin group, 77% in the high-dose group, and 100% in the control group. The adhesion score in the low-dose group was significantly lower (P < 0.01) than in the high-dose and control groups. Peritoneal thromboxane decreased significantly during treatment in both low-dose and high-dose aspirin groups, whereas prostacyclin decreased only in the high-dose group. Postoperative adhesion reduction observed in this study with low-dose aspirin treatment could be due to the selective inhibition of thromboxane over prostacyclin production.     

The role of neutrophils in peritoneal adhesion formation

The most common cause of intraperitoneal adhesions is previous abdominal surgery. Postoperative adhesion formation results from a fibroproliferative inflammatory reaction that begins with an influx of polymorphonuclear leukocytes (PMNs) into the peritoneal cavity. Adherence of the PMNs to the endothelial cells (EC) is necessary for PMN migration into the tissue in response to a stimulus. Several receptor-counterreceptor pairs of ligands such as CD11/CD18 on the PMN and ICAM-1 (CD54) on EC have been identified. Monoclonal antibody against CD11/CD18 (R15.7) inhibits PMN adherence and migration and consequently protects against PMN-induced tissue injuries. We therefore studied the effect of preventing PMN-EC adherence, using anti-CD18 monoclonal antibody, on postoperative adhesion formation in rabbits. Group 1 was a control receiving physiologic saline, and group 2 received anti-CD18 antibody (R15.7, 2 mg/kg). The treatment was administered iv at the end of surgery and repeated on the first and second postoperative days. Peritoneal adhesions were induced at laparotomy by repairing two peritoneal defects, by oversewing the defect (model 1), and by resuturing the removed parietal peritoneum in its place as an ischemic graft (model 2). Adhesions were evaluated blindly at 10 days after operation by measuring the percentage of the suture line covered with adhesions (model 1) or by a scoring system (model 2). All control animals developed intraperitoneal adhesions and the percentage of the suture line covered with adhesions was 25 +/- 5.9% (mean +/- SEM) and the mean score in model 2 was 0.9 +/- 0.2. Anti-CD18 antibody, R15.7, increased the degree of postoperative adhesion formation in both models, but the results were significant only in model 2. Also, anti-CD18 antibody significantly decreased peritoneal neutrophils from 11.1 x 10(7) +/- 1.8 x 10(7) to 2.2 x 10(7) +/- 0.4 x 10(7) (P < 0.001) on the first postoperative day. It is concluded that inhibition of PMN-EC adherence does influence the postoperative adhesion formation. These results might suggest that PMNs have a role in modulating postoperative adhesion formation.     

Development of ovarian pathology after hysterectomy without oophorectomy

This study was done to determine the occurrence of disease in retained ovaries after hysterectomy. A retrospective analysis of patient charts was performed, comparing the patient reports of women who had secondary ovarian lesions with those whose ovaries showed no pathologic findings during the ten year period of observation (1980 to 1990). The study included 1,265 women with at least one ovary saved after hysterectomy for benign indications. Main outcome measures were ovarian pathologic findings after hysterectomy requiring repeat operation. The overall incidence of lesions in retained ovaries was 3.95 percent. There was a 3 percent risk of having secondary ovarian pathologic findings within three years after hysterectomy, with a decreased risk for the following seven years (mean follow-up time of 60 months, range of three to 120 months). Histologic findings at reoperation included common benign conditions of the ovary. No instance of carcinoma of the ovary was found. The risk of having pathology in the retained ovaries after hysterectomy was significantly higher in women who had only one ovary saved, compared with those who had both ovaries saved (7.63 versus 3.47 percent; p < 0.05). The mean age at hysterectomy was significantly lower in women who had ovarian disorders subsequent to hysterectomy than in those who did not (39.3 versus 43.9 years; p < 0.001). In the group of women with secondary ovarian lesions, mean parity was significantly lower than in those without reoperation (1.22 versus 1.94; p < 0.0001). Women with unilateral oophorectomy at the time of hysterectomy had twice the risk of secondary ovarian lesions, compared with those without oophorectomy at hysterectomy. Determinants, such as age, parity and gravidity must be considered when deciding whether or not to perform oophorectomy at hysterectomy.     

Protective effect of natural TNF-binding protein on human TNF-induced toxicity in mice

Three techniques for closing the ovary have been compared. The test was carried out on 30 rats' ovaries. After the ovary had been cut with scissors it was closed with rapid acting Tissucol (a biological glue) or closed with interrupted stitches of 10/0 Vicryl, or left to close by itself. Sixty days later the ovaries were looked at macroscopically and histologically. The macroscopic score was established according to the presence of adhesions, the size of the ovary, the presence of cysts; and the histological score was carried out according to the presence of granulomatous macrophage lesions, the degree of fibrosis and the existence of germ cell cysts. The results were identifically the same as far as these five different criteria were concerned. All the same, Tissucol brought about less fibrosis and less atrophy of the ovary. Tissucol, therefore, is a good alternative for suturing the ovary as compared with stitching or no formal closure after the removal of ovarian cysts, particularly laparoscopically.     

The effect of training and duration of surgery on adhesion formation in the rabbit model

In order to evaluate the effect of training upon postoperative adhesions, standard bipolar and mechanical, nonopposing injuries were performed in the uterine horns and side walls of 52 mature female rabbits using a conventional three-puncture laparoscopy, by an endoscopic surgeon with limited experience. An additional injury, either bipolar or mechanical or both, was performed in the retro-uterine space. With experience, the duration of surgery decreased progressively from 12 +/- 2 to 8 +/- 1 min in the first and last 10 animals respectively. The amount of perioperative bleeding was not affected by experience. With experience the postoperative adhesions decreased in extent (P = 0.0001), tenacity (P = 0.004), type (P = 0.002) and inflammation (P = 0.003) and for total score (P = 0.0002). These changes were correlated with the briefer duration of surgery but not with the amount of perioperative bleeding. The strong correlations of adhesion scores in the pouch of Douglas, and around both uterine horns confirmed the importance of the inter-animal variability in making adhesions. By logistic regression, the adhesions in the pouch of Douglas were explained simultaneously by the adhesions on the uterine horns (P = 0.0004, thus correcting for inter-animal variability) by the amount of bleeding (P = 0.01) and the duration of surgery (P = 0.05). No major differences were found in adhesions following a mechanical or a bipolar injury or following such a lesion in the pouch of Douglas or at the uterine horns. In conclusion, experience, expressed by the duration of surgery and to a lesser extent perioperative bleeding, is a major co-factor in postoperative adhesions, suggesting that duration of surgery should be strictly standardized in endoscopic adhesion studies. The important inter-animal variability can be circumvented by using a standard control lesion, making each animal its own control.     

The rates of adhesion development and the effects of crystalloid solutions on adhesion development in pelvic surgery

OBJECTIVE: To document rates of adhesion development after abdomino-pelvic surgery, stratified by adhesion type, access method, and use of crystalloid solution instillates. DESIGN: Reports from a MEDLINE search (1/1/1966-12/18/1996) detailing rates of adhesion development and meeting the inclusion criteria were subjected to meta-analysis. SETTING: Meta-analysis. PATIENT(S): Patients undergoing abdomino-pelvic surgery. INTERVENTION(S): Intraperitoneal crystalloid solution instillates. MAIN OUTCOME MEASURE(S): Percentage adhesion-free outcome in patients ("patients") or surgical sites ("sites"). RESULT(S): Adhesion-free outcome (sites) was lowest for reformed (26.3% laparotomy; 14.3% laparoscopy), higher for de novo 1b (direct trauma) (45.2% laparotomy, 37.2% laparoscopy), and highest for de novo 1a (indirect trauma) adhesions (82.4% laparoscopy). Crystalloid solution instillates reduced adhesion-free outcome at sites (45.2% versus 20% de novo 1b adhesions in laparotomy) and in patients (43.5% versus 19.9% reformed, laparotomy; 71.7% versus 25% de novo 1b, laparoscopy). CONCLUSION(S): Adhesion-free outcome was lowest for reformed, higher for de novo 1b, and highest for de novo 1a adhesions. Surprisingly, it was lower in laparoscopy than in laparotomy for de novo 1b and reformed adhesions. Crystalloid instillates did not increase adhesion-free outcome. Although limited by the retrospective and heterogeneous nature of the data, these conclusions nonetheless provide a basis on which to formulate future hypotheses.     

Resource utilization in the emergency department: the duty of stewardship

OBJECTIVE: Our purpose was to determine whether there is a difference in adhesion formation after pelvic and paraaortic lymphadenectomy with transperitoneal laparoscopy compared with both extraperitoneal laparotomy and transperitoneal laparotomy in a porcine model. STUDY DESIGN: Ninety female hogs underwent pelvic and paraaortic lymphadenectomy: 40 with transperitoneal laparoscopy, 40 with extraperitoneal laparotomy, and 10 with transperitoneal laparotomy. Three weeks after the initial surgery, a laparotomy was performed to assess adhesion formation. RESULTS: The transperitoneal laparotomy group had significantly higher adhesion formation, with a 100% (10 of 10) adhesion rate. In the transperitoneal laparoscopy group, 12 of 40 hogs (30%) had adhesions develop versus 8 of 38 (21%) in the extraperitoneal laparotomy group (p = not significant). Also no differences were found in the transperitoneal laparoscopy and extraperitoneal laparotomy groups when comparing adhesion thickness or the total surface area of adhesions. More anterior abdominal wall adhesions were noted in the extraperitoneal laparotomy group (5 of 38) than in the transperitoneal laparoscopy group (0 of 40, p = 0.02). CONCLUSIONS: Pelvic and paraaortic lymphadenectomy performed with transperitoneal laparoscopy does not increase adhesion formation when compared with extraperitoneal laparotomy in a porcine model. The transperitoneal laparoscopy (and extraperitoneal laparotomy) approach also induces significantly fewer adhesions than transperitoneal laparotomy.     

Clinical evaluation of 0.5% ferric hyaluronate adhesion prevention gel for the reduction of adhesions following peritoneal cavity surgery: open-label pilot study

The objective of this study was to assess the safety and to make a preliminary assessment of the efficacy of 0.5% ferric hyaluronate adhesion prevention gel in reducing adhesions in patients undergoing peritoneal cavity surgery by laparotomy, with a planned 'second-look' laparoscopy. The study was a randomized, open-label, placebo-controlled, parallel-group design in patients desirous of fertility at the Women's and Children's Hospital, Department of Obstetrics and Gynecology, University of Southern California School of Medicine, Los Angeles, California. Female patients aged 24 to 41 years received 300 ml 0.5% ferric hyaluronate adhesion prevention gel or lactated Ringer's solution as an intraperitoneal instillate at the completion of the laparotomy procedure. At second-look laparoscopy 4-12 weeks after the laparotomy, the presence of adhesions was evaluated. Haematology and serum chemistry were determined throughout the study interval. All patients tolerated the procedures well and did not manifest any serious adverse events. At second-look laparoscopy, patients treated with 0.5% ferric hyaluronate adhesion prevention gel had significantly fewer adhesions than control patients. When adhesions did form, they were significantly less extensive and less severe in patients who received 0.5% ferric hyaluronate adhesion prevention gel. In conclusion, 0.5% ferric hyaluronate adhesion prevention gel was safe and highly efficacious in the reduction of the number, severity and extent of adhesions throughout the entire abdomen following peritoneal cavity surgery.     

Prevention of de-novo adhesion formation after laparoscopic myomectomy: a randomized trial to evaluate the effectiveness of an oxidized regenerated cellulose absorbable barrier

To evaluate the effectiveness of the oxidized regenerated cellulose absorbable barrier (Interceed, TC7) in the prevention of de-novo adhesion formation after laparoscopic myomectomy, a prospective and randomized study was performed at the Department of Obstetrics and Gynaecology of the University of Cagliari, Cagliari, Italy. A total of 50 pre-menopausal non-pregnant women, aged 23-42 years, who submitted to laparoscopic myomectomy from January 1993 to June 1994, were randomized to surgery alone (control group, n = 25) or surgery and oxidized regenerated cellulose barrier (Interceed group, n = 25). Neither group received any other treatment for adhesion prevention. A second-look laparoscopy was performed 12-14 weeks after laparoscopic myomectomy. The incidence of adhesion-free patients was assessed at second-look laparoscopy by an investigator not informed of the treatment. The numbers of adhesion-free patients were three out of 25 (12%) in the control group and 15 out of 25 (60%) in the treatment group (P < 0.05). In conclusion, the oxidized regenerated cellulose absorbable barrier significantly reduced de-novo adhesion formation after laparoscopic myomectomy.     

Native CSF spectrophotometry--contribution to the differential diagnosis of closed cranial injuries

The development of postoperative peritoneal adhesions was studied in rats and rabbits, the frequency of adhesions in the experimental model used being very high. In the development of an adhesion, fibrin seems to be an important contributor to the bridge between different tissues. Dextran, which modifies the fibrin network and makes it more susceptible to lysis, was used as a possible prophylactic agent, but we found no difference between treated and control groups. It is concluded that the stimulus for fibrin formation in the peritoneal adhesions using this atraumatic model was too strong to be overcome by the normal fibrinolytic system. The anti-inflammatory reaction of hyaluronic acid did not diminish the frequency or degree of adhesions.     

Prevention of post-surgical adhesion formation using aspirin in a rodent model: a preliminary report

Pelvic adhesions are one of the major factors which significantly and adversely affect surgery outcome due to intra- and postoperative morbidity and reduce future female fertility. Using a rodent model, we evaluated the efficacy of aspirin, a non-steroidal anti-inflammatory drug, in the prevention of adhesion formation. A total of 72 female Wistar rats received a standardized primary traumatic lesion to the right uterine horn. They were randomly divided into eight groups: group I (control) had no treatment and group II received a single pre-operative 0.70 mg aspirin. All the succeeding groups (III-VIII) received aspirin in doses of 0.35, 0.70, or 1.40 mg every 6 h for either 48 or 96 h in addition to the pre-operative aspirin (0.70 mg). All animals were killed 4 weeks later and adhesions were assessed using a modified adhesion scoring scale. The lowest adhesion score was found in the group treated with 0.35 mg of aspirin for 96 h, and the highest was found among the groups treated with either 0.70 or 1.40 mg for 48-96 h respectively (P < 0.05). These results are in line with the hypothesis that administration of a low dose of aspirin selectively inhibits the production of thromboxane A2, whereas basal prostacyclin biosynthesis is preserved. This phenomenon might contribute to reducing postoperative adhesion formation in a rat model. Thus, future studies into the prevention of adhesion formation may require the additional use of a non-steroidal anti-inflammatory drug, for which aspirin deserves further attention, before extrapolation into human therapy.     

Estradiol-mediated suppression of apoptosis in the rabbit corpus luteum is associated with a shift in expression of bcl-2 family members favoring cellular survival

In the rabbit, estradiol is the primary luteotropic hormone. Estradiol withdrawal results in a rapid decline in serum progesterone and eventually in corpus luteum (CL) regression. The objective of this study was to determine whether estradiol modulates luteal cell apoptosis. In the first experiment, rabbits were randomly assigned to one of five experimental groups. An empty capsule (control) or estradiol-filled Silastic capsule was inserted s.c. on Day 0 of pseudopregnancy (day of hCG administration). On Day 11 of pseudopregnancy, some of the group I (control) and group II (estradiol capsule) rabbits were subjected to laparotomy, and one ovary from each rabbit was perfused in vitro to determine progesterone secretion rates. The CL from the contralateral ovary were dissected, snap-frozen, and stored at -70 degrees C until analyzed for internucleosomal DNA cleavage (apoptosis). Estradiol-containing capsules were removed from some of the remaining rabbits on Days 8, 9, and 10 to initiate estradiol deprivation. Rabbits were then subjected to laparotomy 24, 48, or 72 h after capsule removal (groups III, IV, and V, respectively), and ovaries or CL were processed as described above. Deprivation of estradiol for 24 (group III), 48 (group IV), or 72 (group V) h in vivo reduced in vitro progesterone secretion rates by more than 90% as compared to that in ovaries collected from estradiol capsule-intact animals. After in vivo endogenous estradiol suppression, withdrawal of exogenous estradiol resulted in luteal cell apoptosis, which increased in a time-dependent manner. Northern blot analysis revealed an increase in bax mRNA levels and a decrease in bcl-x mRNA levels coincident with luteal cell apoptosis induced by estradiol withdrawal. These data demonstrate that changes in progesterone production caused by estradiol exposure and deprivation are in part related to luteal cell apoptosis, and alterations in the expression of bcl-2 gene family members may be one of the mechanisms by which estradiol exerts its luteotropic effect in the rabbit CL.     

Interaction of Interceed oxidized regenerated cellulose with macrophages: a potential mechanism by which Interceed may prevent adhesions

OBJECTIVE: The objective of the study was to determine whether Interceed oxidized regenerated cellulose (Johnson & Johnson Medical, Arlington, Tex.), because of its polyanionic nature, may compete for the macrophage scavenger receptor. STUDY DESIGN: RAW macrophages were incubated with Interceed oxidized regenerated cellulose and known scavenger receptor ligands. The production of interleukin-1beta by mouse peritoneal macrophages was measured in the presence of Interceed cellulose. RESULTS: When macrophages were incubated with Interceed cellulose, increasing concentrations inhibited the uptake of fluorescent acetyl low-density lipoprotein. In the presence of Interceed cellulose there was a decrease in the production of interleukin-1beta by mouse macrophages. CONCLUSION: These results suggest that the interaction of Interceed oxidized regenerated cellulose with macrophages with scavenger receptors may result in a decreased secretion of matrix components, inflammatory mediators, and cellular growth factors. Thus Interceed cellulose may function as a biologic barrier in preventing adhesions.     

Tailored hydrophobic cavities in oligonucleotide-steroid conjugates

BACKGROUND: The extent of adhesion formation following both open and laparoscopic surgery remains unclear. This study aimed to evaluate the extent of postoperative adhesion formation after laparoscopic and open fundoplication in a rat model. METHODS: Fifty-two male Sprague-Dawley rats were randomized into four groups: laparoscopic fundoplication (n = 20), open fundoplication (n = 20), laparoscopy (n = 6) and laparotomy (n = 6). Blood as well as intraperitoneal fluid was sampled for tumour necrosis factor (TNF) alpha measurement by enzyme-linked immunosorbent assay. All the rats were killed 3 weeks after operation, and adhesion formation was evaluated using a standardized scoring system. RESULTS: There were no intergroup differences in body-weight gain after surgery. The overall mortality rate was 19 per cent and death was observed only in the fundoplication groups. Animals that had open fundoplication developed significantly more adhesions than those that underwent laparoscopic fundoplication (34 versus 21). Laparoscopic surgery induced predominantly parietal adhesions, whereas open surgery was more associated with visceral adhesions. The adhesions observed in the laparoscopic groups were significant thinner than those after open surgery and the tenacity of adhesions was decreased in laparoscopic compared with open surgery. The peak plasma level of TNF-alpha was reached during laparoscopic fundoplication, whereas the peak level was observed 3 h after open fundoplication. Intraperitoneal TNF-alpha levels showed no significant differences at 3 h. CONCLUSION: These findings indicate that laparoscopic fundoplication in rats leads to less severe adhesions of a different type (parietal) compared with those seen in the open controls.     

Hypergonadotropic secondary amenorrhea: clinical analysis of 126 cases

OBJECTIVE: To study the etiology and early diagnosis of hypergonadotropic amenorrhea and to explore the appropriate treatment for preserving their reproductive function. METHODS: 126 cases of secondary amenorrhea with serum follicular stimulating hormone (FSH) levels > or = 40 IU/I, were analysed. Their clinical manifestations, karyotypes, ovarian morphology and histology, reproductive hormone assays, and responses to estrogen therapy and ovulation induction were studied. RESULTS: 6 cases presented with histories of ovarian surgery, radiotherapy or chemotherapy. Among the other 120 cases, 18 manifested amenorrhea before or at 25 years of age, 102 developed amenorrhea after age 25. In the former group, 16 (88.9%) showed unilateral or bilateral gonadal dysgenesis, and the other 2(11.1%) were defined as resistant ovaries. Abnormalities of sex chromosome karyotype occurred in 44.4% (8/ 18). In the latter group, 68 underwent laparotomy or laparoscopy examination. Morphological and histological examinations of both ovaries showed atrophic ovaries in all cases accompanied by 30.9% (21/ 68) unilateral gonadal dysgenesis; sex chromosomal abnormality was found in only one with no sexual immaturation. The efficacy of estrogen treatment was significantly better among cases with amenorrhea less than 1 year as compared with those longer than 1 year. Clomiphene challenge test given to 8 cases during their irregular menstrual stages produced an elevation of FSH levels to > 20 IU/I. without any response of estradiol secretion. CONCLUSIONS: The earlier estrogen therapy is initiated, the greater possibility of pregnancy will be achieved in cases suffering from hypergonadotropic amenorrhea. The clomiphene challenge test may provide evidence of waning ovarian function for early diagnosis.     

Circulating neutrophils and liver injury in rat models of experimental alcoholic liver disease

The present study examined the effects of progesterone (P4) treatments on estrous cyclicity and the loss of ovarian follicles during aging. Young rats received repeated treatments with P4 or empty implants between 3.5 and 8 mo of age. At 8 mo, ovaries were obtained from some animals to determine the numbers of resting follicles, and estrous cycle patterns and hormone levels were determined from other groups of treated females. In contrast to the cyclic increases in P4, estradiol (E2), LH, and FSH in control animals, P4-implanted rats exhibited elevated serum P4 but low E2, LH, and FSH levels. After implant treatments, the follicular reserve was significantly (p < 0.05) larger in P4-treated females (2012 +/- 297 resting follicles per ovary, n = 5 rats per group) than in regularly cyclic control rats (713 +/- 226 follicles per ovary, n = 7). The effects of P4 implants on the follicular reserve were associated with a subsequently higher incidence of regular estrous cycles after P4 treatment. These results demonstrate that P4 prevents cyclic increases in E2 secretion and is associated with a conservation of the ovarian follicular reserve and the maintenance of regular estrous cycle patterns, indicating a protective effect of P4 on the age-related loss of ovarian follicles.     

Locally produced angiotensin II induces ovulation by stimulating prostaglandin production in in vitro perfused rabbit ovaries

The present study was undertaken to investigate the role of exogenous and endogenous angiotensin II (Ang II) in ovarian steroidogenesis and production of prostaglandin (PG) in in vitro perfused rabbit ovaries. The addition of 100 or 10 micrograms Ang II at 2-h intervals to the perfusate did not stimulate progesterone production, but significantly stimulated estradiol (E2) production by perfused rabbit ovaries. When the specific antagonist of Ang II, saralasin at 2 x 10(-6) M, was added to the perfusate 30 min before the onset of Ang II administration, Ang II-stimulated production of E2 was significantly blocked. Ang II also significantly stimulated both PGE2 and PGF2 alpha production, while the addition of saralasin to the perfusate significantly inhibited the Ang II-stimulated production of PG. The levels of PGs in ovaries perfused with saralasin plus 100 micrograms Ang II did not differ significantly from those in control ovaries perfused with medium alone. Exposure to human CG (hCG) significantly stimulated production of progesterone and E2 by perfused rabbit ovaries, while the concomitant administration of 2 x 10(-6) M saralasin significantly reduced only E2 production. Addition of saralasin to the perfusate inhibited hCG-stimulated PG production in a dose-dependent manner. The ovulatory efficiency in ovaries treated with hCG alone or hCG plus saralasin was significantly correlated with PG production by perfused rabbit ovaries at 12 h after exposure to hCG. The production of PG stimulated by Ang II was completely reduced by indomethacin treatment during the entire perfusion period. Indomethacin completely blocked Ang II-induced ovulation, but not Ang II-stimulated oocyte maturation. Concurrent administration of staurosporine, a protein kinase C inhibitor, at 10(-6) M significantly inhibited Ang II-stimulated meiotic maturation of ovulated ova and follicular oocytes. In conclusion, these results indicate that Ang II has a direct role in ovarian production of E2 and PG. An intrinsic renin-angiotensin system in the rabbit ovary may act as an intermediary of gonadotropin-stimulated PG production. Locally produced Ang II may induce ovulation in the rabbit ovary, at least in part, by stimulating PG production.     

Hyperreactio luteinalis in pregnancy

We report on the extremely rare case of ovarian overstimulation in a single pregnancy without prior hormonal stimulation therapy. During the 26th week of gestation ultrasound examination showed a 103 x 57 x 78 mm polycystic tumour with echogenic structures inside the cysts, located behind the uterus. Further management consisted of laparotomy with partial resection of a cystic part of the left ovary. Frozen section examination confirmed the diagnosis of hyperreactio luteinalis and excluded malignancy. To avoid torsion of the ovaries, cysts from both sides were aspirated. On day 8 and 18 after surgery, sonography revealed no pathological finding. In the 40th week of gestation, a healthy baby was delivered. The possibility of a hyperreactio luteinalis has to be kept in mind, when cystic solid tumours of the ovaries are diagnosed during pregnancy. A conservative management is appropriate, because a normal spontaneous remission occurs after delivery.     

Granular-lattice (Avellino) corneal dystrophy

Smooth muscle differentiation in the ovary is rare, and its histopathologic spectrum, including ovarian smooth muscle metaplasia (SMM), has not been well described. The clinicopathologic findings in 48 ovaries with SMM from 40 women are reported. The average age of women with ovarian SMM was 55.6 years (range, 34 to 86 years). Foci of SMM were semiquantitatively characterized as 1+ in 46% (1 to 3 foci), 2+ in 37% (4 to 6 foci), and 3+ in 17% (> 6 foci). SMM was bilateral in 8 (23%) of the 35 patients who had bilateral oophorectomies. SMM was intimately associated with another ovarian process in 28 (58%) cases, including ovarian cysts (11), endometriosis (3), granulosa cell tumors (3), extensive stromal luteinization (1), ovarian fibroma (1), adhesions (1), and folliculogenesis (8). Ovaries with 2+ to 3+ SMM were associated with another ovarian lesion significantly more often than those with 1+ SMM (p < 0.01). Most women with ovarian SMM (86%) also had uterine leiomyomas. Significant endometrial pathology was present in 13 (37%) of 35 simultaneously removed uteri. In conclusion, SMM occurs most often in perimenopausal or postmenopausal women, most of whom also have uterine leiomyomas. Ovarian SMM is usually confined to a few microscopic fields, is bilateral in < 25% of patients, and is often associated with other ovarian lesions.