Treatment with laparoscopy

Surgery is not usually done to treat pelvic inflammatory disease (PID). Ninety percent of patients with PID respond to medical therapy if no TOA is present. Most patients respond to IV antibiotics alone if a TOA is smaller than 7 cm.

Some indications for surgery are:

• Failure to respond within 48 to 72 hours of medical management
• Need to drain or remove an abscess, such as a tubo-ovarian abscess.
• Cut scar tissue (adhesions) that is causing pain [10,13].

Surgical therapy is necessary in a round 25% of patients treated for TOA. TOA diameter larger than 8 cm were less likely to respond to antimicrobial treatment than smaller abscesses [20]. Akyol et al, 1998, reported that they performed surgical therapy of their patients for TOA in 28,5% [20].

Arda et al, 2004, in their study about TOA in a sexually inactive adolescent patient concluded that laparoscopic surgery which minimises postoperative complications should be the first option in the treatment of TOA. Because early diagnosis and treatment are needed to prevent future sequelae causing infertility [21].

Protopapas AG et al, 2004, in their study reviewing the incidence of gynecological malignancy in menopausal women who develop tubo-ovarian abscesses. They concluded that postmenopausal women presenting with TOAs, should be thoroughly investigated. Conservative treatment of TOAs has no place during the menopause because of a significant concomitant gynecological malignancy was found including a variety of cancers [22].

Intra abdominal ruptured of tubo-ovarian abscess remains controversial and generally is decided on the basis of the patient’s age, parity and clinical circumstances[23]. Rupture of TOA is a surgical emergency with a very high mortality rate. Aggressive surveillance for the presence of a TOA and prompt inpatient medical management is required. Diagnosis of a ruptured TOA must be consider if the patient has increased peritoneal signs and a rigid abdomen [16].

Michael W et al, reported a rare case of fatal S pneumoniae infection from a tuboovarian abscess. At autopsy, a 6-cm tuboovarian abscess (TOA) was documented, with pathologic evidence of severe suppurative oophoritis of the right ovary [24].

Laparoscopy Prosedure:

• Laparoscopy was performed under general anesthesia by the conventional three-puncture technique.
• In all but one case with clinically suspected acute PID; the laparoscopic PID diagnosis was based on commonly accepted visual findings
• Acute salpingitis was diagnosed when a hyperemic edematous fallopian tube was visible, with no sign of intraluminal pus. A pyosalpinx was diagnosed as an enlarged, edematous tube with partial or total destruction of the fimbriated end.
• A TOA was diagnosed when the ovary and the Fallopian tube could not be distinguished from each other, forming an adnexal complex with abscess formation.
• Salpingitis was considered mild PID, whereas pyosalpinx and TOA were considered severe PID.

In patients with laparoscopically proven PID, one or more of the following procedures were performed:

• Lysis of pelvic adhesions, drainage and irrigation of pyosalpinges and TOAs, and extirpation of a unilateral infectious complex.
• Irrigation of the pelvic cavity with 2 liters of physiologic saline was performed in all cases.
• Patients with disease other than PID were treated laparoscopically when possible. But in certain cases, appendectomy was performed by laparotomy for severe infection
• All laparoscopies were documented by videotape.
• Unnecessary antimicrobial therapy was ended in patients with no sign of infectious disease in laparoscopy [17].

Although in the past, tubo-ovarian abscess occurred primarily in an older women age group; over the past several decades, a progressively younger patients group have been encountered. The young patient with a tubo-ovarian abscess who desires to maintain reproductive function presents a significant dilemma to the gynaecologist today [23]. However, in Buchweitz’s study, 2002, he concluded that if laparoscopic treatment of TOA is performed, organ-preserving treatment (incision of the abscess cavity and lavage) should be preferred in order to reduce the risk of complications compare with laparoscopic salpingectomy or salpingo-oophorectomy (ablative treatment). This choice should be made irrespective of the patient's age or desire to remain fertile [25].

Yang et al, 2002, in their study with 69 women demonstrated that laparoscopy surgery had significant advantage over conventional laparotomy. It decreases hospital stay, had a lower percentage of wound infection, and had a shorter time for fever to subside. Advantages of open laparoscopic surgery over exploratory laparotomy in patients with tubo-ovarian abscess. They also concluded that although management of TOA consists of conservative medical treatment with antibiotics, it is now widely accepted that surgical intervention should be pursued early after the diagnosis [26].

DISCUSSION

Despite the development of new diagnostic aids, pelvic inflammatory disease (PID) is still poorly recognized and managed. Misdiagnosed of PID will consequence with potentially serious sequelae, particularly in fertile age women could become infertile.

Patients of fertile age represent an especially difficult patient group because of a variety differential diagnose of gynecologic and non-gynecologic.

Various imaging methods have been proposed for the diagnosis of PID. Transvaginal sonography (TVS) is routinely used in the diagnosis of acute gynecologic disorders. An overall concern is the poor performance of TVS in mild PID. CT scan has been found than be superior to USG for the detection of tubo-ovarian abscess (78-100% sensitivity) as compared to ultrasound with a sensitivity of 75 - 82%. In the diagnosis of intra-abdominal conditions, magnetic resonance imaging (MRI) has been widely accepted, although MRI has been used rarely in the imaging of adnexal masses and gynecologic infections. In a scenario of questionable diagnosis or if there is evidence of rupture of tuboovarian abscess immediate surgical intervention is recommended.

Drainage and appropriate use of broad-spectrum antibiotics are indispensable in treatment. In patients who failed to respond, laparoscopy or laparotomy was performed. For 20 Years, laparoscopy has been the gold standard for the diagnosis and treatment of TOA. The operative procedure involves blunt lysis and hydrodissection of adhesions, drainage of the abscess cavity, aspiration of purulent fluid from the pelvis, removal of necrosis, and irrigation of the peritoneal cavity. And compared to laparotomi, if there is no rupture of TOA or peritonitis, usually laparoscopy should be prefered Effective management laparoscopically will prevents complications associated with delayed treatment and often preserves the patient’s fertility. Some studies indicate that operative laparoscopy may improve the primary recovery of acute PID patients. Laparoscopic surgery which minimises postoperative complications should be the first option in the treatment of TOA.

CONCLUSION

Treatment of PID and TOA primarily should be with antibiotic,however if there is no respond in 3 days or clinical diagnosis remain unclear further measurement both for diagnostic and therapeutic have to be considered.

Laparoscopy offers the possibility to diagnose and manage PID more early, safely and probably cost-effectively. Effective management prevents complications associated with delayed treatment and often preserves the patient’s fertility or even catastrophic. Laparoscopy also improve the primary recovery of acute PID patients

Reference:

1. Kathe Gallagher, MSW, Tubo-ovarian abscess and pelvic, inflammatory disease, Family Medicine, January 30, 2007
2. O. Buchweitz, E. Malik, P. Kressin, A. Meyhoefer-Malik, K. Diedrich, Laparoscopic management of tubo-ovarian abscesses, Retrospective analysis of 60 cases, University of Luebeck, Ratzeburger Allee 160, 23538 Luebeck, GermanReceived, 2000
3. Canadian Guidelines on Sexually Transmitted Infections 2006 Edition- Updated October 2007)
4. STD Treatment Guidelines. //www.cdc.gov/std/
5. Jonathan Ross, Pelvic inflammatory disease, BMJ Clin Evid 2006;09:1606
6. Pelvic Inflammatory Disease, www.ohiorepromed.com/ illustrations.htm
7. Mi Young Kim, Sung Eun Rha, Soon Nam Oh, Young Joon Lee, Seung Eun Jung, Jae Young Byun, MR Imaging Findings of Hydrosallpiinx due to Various Causes: Comprehensive Review and Histopathologic Correlation Department of Radiology. The Catholic University of Korea, 2005
8. Arora D, Pregnancy with ovarian abscess, Case report The Journal of Obstetrics and gynecology of India, J Obstet Gynecol India Vol. 55, No. 2: March/April 2005 Pg 181-182
9. CJ Tseng, Clinical Guideline Pelvic inflammatory disease, Chang Gung Memorial Hospital at ChiaYi, 2005
10. Jason A. Dominitz, M.D., MHS, John H. Sekijima, M.D., and Mary Watts, M.D, Abdominal Pain
11. Ollendoff AT, Oophoritis, emedicine, 2007
12. Y. Kaakaji, H. V. Nghiem, C. Nodell, T. C. Winter, AJR, Sonography of Obstetric and Gynecologic Emergencies: Part II, Gynecologic Emergencies, 2000;174:651–656 0361–803X/00/1743–651
13. Gupta, Nupur Arora, Manju; Singh, Neeta; Dadhwal, Vatsla; Et al, A Clinical Experience of Ruptured Tuboovarian Abscesses, Red orbit, 2007
14. Timo A. Tukeva, Hannu J. Aronen, Pertti T. Karjalainen, Pontus Molander, Timo Paavonen and Jorma Paavonen, MR Imaging in Pelvic Inflammatory Disease: Comparison with Laparoscopy and US, Radiology;210:209-216, 1999.
15. Drs. Ros Sanders Hewett & Richard Lau, Pelvic Inflammatory Disease.Illustration, Department of Genitourinary Medicine, St. George's Hospital,28 September 2001, courtesy of: www.ohiorepromed.com/ illustrations.htm
16. Westrom L and Eschenbach D. In: K. Holmes, P. Sparling, P. Mardh et al (eds), Pelvic Inflammatory Disease. ACOG Patient Education Pamphlet, 1999. Sexually Transmitted Diseases, 3rd Edition. New York: McGraw-Hill, 1999, 783-809.
17. Pontus Molander, Diagnosis and management of patients with clinically suspected acute pelvic inflammatory disease, Helsinki, 2003
18. Pelvic inflammatory disease Surgery,WebMD Medical Reference from Healthwise November 28, 2006) Azziz, Can laparoscopy help you avoid unnecessary treatments?, 2003, sheknows.co