Commentary

In recent years, uterine isthmocele has increasingly been included as part of the differential in women with a history of a cesarean section who present with postmenstrual bleeding, pelvic pain, or secondary infertility.

The defect appears as a fluid-filled, pouch-like abnormality in the anterior uterine wall at the site of a prior cesarean section. The best method for diagnosis is usually a saline-infused sonogram. It can be treated in various ways, depending on the patient’s symptoms and desire for future fertility. Although we have treated isthmoceles with hysteroscopic desiccation, or resection, our best success has occurred with laparoscopic resection and reapproximation of normal tissue in a small series of patients.

There is no standard definition of the defect that fully describes its size, depth, and other characteristics. Many words and phrases have been used to describe the defect: It is commonly referred to as an isthmocele, because of its usual location at the uterine isthmus, but others have referred to it as a cesarean scar defect or niche, as the defect may be found at the endocervical canal or in the lower uterine segment. In any case, while diagnoses appear to be increasing, the incidence of the defect is unknown.

More research on risk factors and treatment is needed, but the literature, as well as our own experience, has demonstrated that this treatable defect should be considered in the differential diagnosis for women who have undergone cesarean section and subsequently have abnormal bleeding or staining, pelvic pain, or secondary infertility, especially when fluid is clearly visible in the cesarean section defect.

Diagnosis, symptoms

An isthmocele forms in the first place, it is thought, after an incision scar forms and causes retraction and dilation in the thinner, lower segment of the anterior wall and a thickening in the upper portion. There is a deficient scar, in other words, with disparate wound healing on the sides of the incision site.

The defect and its consequences were described in 1995 by Dr. Hugh Morris, who studied hysterectomy specimens in 51 women with a history of cesarean section (in most cases, more than one). Dr. Morris concluded that scar tissue in these patients contributed to significant pathological changes and anatomical abnormalities that, in turn, gave rise to a variety of clinical symptoms including menorrhagia, dysmenorrhea, dyspareunia, and lower abdominal pain refractory to medical management.

Distortion and widening of the lower uterine segment and “free” red blood cells in endometrial stroma of the scar were the most frequently identified pathological changes, followed by fragmentation and breakdown of the endometrium of the scar, and iatrogenic adenomyosis (Int. J. Gynecol. Pathol.1995;14:16-20).

Several small reports and case series published in the late 1990s offered additional support for a cause-and-effect correlation between cesarean scar defects and abnormal vaginal bleeding. Several years later, the link was strengthened as more investigators reported connections between the defects and various symptoms. These reports were followed by published comparisons of imaging techniques for the diagnosis of isthmoceles.

Diagnosis of the defects can be made with transvaginal ultrasound (TVUS), saline infused sonohysterogram (SIS), hysterosalpingogram, hysteroscopy, and magnetic resonance imaging (MRI). With any modality, imaging is best performed in the early proliferative phase, right after the menstrual cycle has ended.

Courtesy of Dr. Kirsten Sasaki

Comparisons of unenhanced TVUS and SIS – both of which may be easily performed in the office and at a much lower cost than MRI – have shown the latter technique to be superior for evaluating isthmoceles. Distension of the endometrial cavity makes the borders of the defects easier to delineate, which enables detection of more subtle defects and improves our ability to measure the size of defects.

This advantage was described by in 2010 by Dr. O. Vikhareva Osser and colleagues, who performed both TVUS and SIS in 108 women with a history of one or more cesarean sections. They identified more scar defects with SIS than with TVUS (Ultrasound Obstet. Gynecol. 2010;35:75-83).

Another benefit of SIS over TVUS and hysterosalpingogram is that one can measure the thickness of the remaining myometrium overlying the isthmocele, which is especially important knowledge for patients considering another pregnancy. As a result, we have relied on this technique to diagnose every case within our practice. I will perform SIS in a patient who has a history of one or multiple cesarean sections and symptoms of abnormal bleeding, pelvic pain, or secondary infertility as part of the basic work-up.

Similarly, an observational prospective cohort study of 225 women who had undergone a cesarean section 6-12 months prior compared TVUS and gel-infused sonohysterogram (GIS), and found that the prevalence of a niche – defined as an anechoic area at the site of the cesarean scar, with a depth of at least 1 mm on GIS – was 24% with TVUS and 56% with GIS (Ultrasound Obstet. Gynecol. 2011;37:93-9).

The abnormal bleeding is often described by patients as spotting or bleeding that continues for days or weeks after menstrual flow has ended; it is believed to result from an accumulation of blood in the defect and a lack of coordinated muscle contractions, which leads to continued accumulation of blood and menstrual debris. Dysmenorrhea and chronic pelvic pain are thought to be associated with iatrogenic adenomyosis and/or a chronic inflammatory state created when accumulated blood and mucus are intermittently expelled. Secondary infertility can occur, it is believed, as accumulated fluid and blood interfere with the endocervical and even the endometrial environment and disrupt sperm transport, sperm quality, and embryo implantation. Difficulty in embryo transfer may also occur because of the distortion caused to the endometrial cavity. Many of the isthmoceles that we and others have diagnosed have been in patients undergoing invitro fertilization. The patients are often found to have an accumulation of fluid in the endometrial canal and isthmocele during stimulation for either a fresh or frozen embryo transfer, thus necessitating the cancellation of their cycle.

Treatment

The choice of treatment depends upon the patient’s symptoms and desire for future fertility, but it can include hormonal treatment, hysteroscopic resection, transvaginal repair, a laparoscopic or robot-assisted approach, and hysterectomy.

Little has been published on nonsurgical treatment, but this may be considered for patients whose primary symptoms are bleeding or pain and who desire the least invasive option. In a small observational study of women with an isthmocele and bleeding, symptoms were eliminated with several cycles of oral contraceptive pills (Fertil. Steril. 2006;86: 477-9).

Courtesy of Dr. Kirsten Sasaki

Hysteroscopic isthmocele correction or resection are the surgical techniques most frequently described in the literature, but, as with other surgical approaches, studies are small. Hysteroscopic repair has typically involved the use of electrical energy to desiccate or cauterize abnormal tissue and eliminate the outpouching in which blood and fluid accumulate. Hysteroscopic resection is another technique that has also been championed.

However, for patients who desire future pregnancy, we do not recommend a hysteroscopic approach because it does not reinforce the often-thinning myometrium covering the defect. We are concerned that if this area is simply desiccated or resected, and not reapproximated, the patient will be at greater risk of pregnancy-related complications, including cesarean scar ectopic pregnancy with potential uterine dehiscence.

Laparoscopic repair was first described by Dr. Olivier Donnez, who rightly pointed out that the laparoscopic approach offers an optimal view from above during dissection of the vesico-vaginal space. Dr. Donnez used a CO₂ laser to excise fibrotic tissue, followed by laparoscopic closure (Fertil. Steril. 2008;89:974-80).

We have had success with a laparoscopic approach that uses concomitant hysteroscopy. The vesico-uterine peritoneum is incised over the anterior uterine wall, and the bladder is backfilled so that its boundaries may be identified prior to further dissection. With the area exposed, we perform a hysteroscopy to determine the exact location of the isthmocele. As the hysteroscope enters the thinned out isthmocele, the light will be more visible via laparoscopic visualization.

When performing conventional laparoscopy, the isthmocele is excised with an ultrasonic curved blade. We use this instrument because it has no opposing arm and because it enables precise tissue dissection in multiple planes. With harmonic energy, we can limit tissue dessication and destruction, lowering the risk of future pregnancy-related complications. Monopolar scissors are best when a robotic approach is used.

Once the isthmocele is resected, the clean edges are sutured together in two layers. The first layer is sutured in an interrupted mattress-style fashion, to prevent tissue strangulation and necrosis. We use a monofilament nonbarbed delayed-absorbable 3-0 PDS suture on a CT-1 needle – a choice that limits tissue trauma and postoperative inflammation.

Courtesy of Dr. Kirsten Sasaki

Sutures are initially placed at each angle with one or two sutures placed between. These sutures must be placed deep to close the bottom of the defect. A second layer of suture is then placed to imbricate over the initial layer of closure. We utilize 3-0 PDS in a running or mattress style, or a running 3-0 V-Loc suture. Our patients return after 1-3 months for a postoperative image, and are instructed to wait at least 3 months after surgery before attempting conception.

In our experience, of more than 10 patients, symptoms ceased in all patients whose surgery was performed for the indication of abnormal uterine bleeding. The follow-up on our series of patients who underwent the procedure for secondary infertility is ongoing, but the preliminary results are very positive, with resolution of intrauterine fluid in all of the patients, as well as several successful pregnancy outcomes.

A recent systematic review of minimally invasive therapy for symptoms related to an isthmocele shows good outcomes across the 12 included studies but does not offer evidence to favor one treatment over another. The studies show significant reductions in abnormal uterine bleeding and pain, as well as a high rate of satisfaction in most patients after hysteroscopic niche resection or vaginal or laparoscopic niche repair, with a low complication rate (BJOG 2014;121:145-6).

Pregnancies were reported after treatment, but sample sizes and follow-up were insufficient to draw conclusions on pregnancy and delivery outcomes, according to the review. As the reviewers wrote, following patients through their next delivery in larger, higher-quality studies will help provide more guidance for selecting the best isthmocele treatments and implementing these treatments into practice.

Dr. Sasaki reported having no financial disclosures relevant to this Master Class.

In recent years, uterine isthmocele has increasingly been included as part of the differential in women with a history of a cesarean section who present with postmenstrual bleeding, pelvic pain, or secondary infertility.

The defect appears as a fluid-filled, pouch-like abnormality in the anterior uterine wall at the site of a prior cesarean section. The best method for diagnosis is usually a saline-infused sonogram. It can be treated in various ways, depending on the patient’s symptoms and desire for future fertility. Although we have treated isthmoceles with hysteroscopic desiccation, or resection, our best success has occurred with laparoscopic resection and reapproximation of normal tissue in a small series of patients.

There is no standard definition of the defect that fully describes its size, depth, and other characteristics. Many words and phrases have been used to describe the defect: It is commonly referred to as an isthmocele, because of its usual location at the uterine isthmus, but others have referred to it as a cesarean scar defect or niche, as the defect may be found at the endocervical canal or in the lower uterine segment. In any case, while diagnoses appear to be increasing, the incidence of the defect is unknown.

More research on risk factors and treatment is needed, but the literature, as well as our own experience, has demonstrated that this treatable defect should be considered in the differential diagnosis for women who have undergone cesarean section and subsequently have abnormal bleeding or staining, pelvic pain, or secondary infertility, especially when fluid is clearly visible in the cesarean section defect.

Diagnosis, symptoms

An isthmocele forms in the first place, it is thought, after an incision scar forms and causes retraction and dilation in the thinner, lower segment of the anterior wall and a thickening in the upper portion. There is a deficient scar, in other words, with disparate wound healing on the sides of the incision site.

The defect and its consequences were described in 1995 by Dr. Hugh Morris, who studied hysterectomy specimens in 51 women with a history of cesarean section (in most cases, more than one). Dr. Morris concluded that scar tissue in these patients contributed to significant pathological changes and anatomical abnormalities that, in turn, gave rise to a variety of clinical symptoms including menorrhagia, dysmenorrhea, dyspareunia, and lower abdominal pain refractory to medical management.

Distortion and widening of the lower uterine segment and “free” red blood cells in endometrial stroma of the scar were the most frequently identified pathological changes, followed by fragmentation and breakdown of the endometrium of the scar, and iatrogenic adenomyosis (Int. J. Gynecol. Pathol.1995;14:16-20).

Several small reports and case series published in the late 1990s offered additional support for a cause-and-effect correlation between cesarean scar defects and abnormal vaginal bleeding. Several years later, the link was strengthened as more investigators reported connections between the defects and various symptoms. These reports were followed by published comparisons of imaging techniques for the diagnosis of isthmoceles.

Diagnosis of the defects can be made with transvaginal ultrasound (TVUS), saline infused sonohysterogram (SIS), hysterosalpingogram, hysteroscopy, and magnetic resonance imaging (MRI). With any modality, imaging is best performed in the early proliferative phase, right after the menstrual cycle has ended.

Courtesy of Dr. Kirsten Sasaki

Comparisons of unenhanced TVUS and SIS – both of which may be easily performed in the office and at a much lower cost than MRI – have shown the latter technique to be superior for evaluating isthmoceles. Distension of the endometrial cavity makes the borders of the defects easier to delineate, which enables detection of more subtle defects and improves our ability to measure the size of defects.

This advantage was described by in 2010 by Dr. O. Vikhareva Osser and colleagues, who performed both TVUS and SIS in 108 women with a history of one or more cesarean sections. They identified more scar defects with SIS than with TVUS (Ultrasound Obstet. Gynecol. 2010;35:75-83).

Another benefit of SIS over TVUS and hysterosalpingogram is that one can measure the thickness of the remaining myometrium overlying the isthmocele, which is especially important knowledge for patients considering another pregnancy. As a result, we have relied on this technique to diagnose every case within our practice. I will perform SIS in a patient who has a history of one or multiple cesarean sections and symptoms of abnormal bleeding, pelvic pain, or secondary infertility as part of the basic work-up.

Similarly, an observational prospective cohort study of 225 women who had undergone a cesarean section 6-12 months prior compared TVUS and gel-infused sonohysterogram (GIS), and found that the prevalence of a niche – defined as an anechoic area at the site of the cesarean scar, with a depth of at least 1 mm on GIS – was 24% with TVUS and 56% with GIS (Ultrasound Obstet. Gynecol. 2011;37:93-9).

The abnormal bleeding is often described by patients as spotting or bleeding that continues for days or weeks after menstrual flow has ended; it is believed to result from an accumulation of blood in the defect and a lack of coordinated muscle contractions, which leads to continued accumulation of blood and menstrual debris. Dysmenorrhea and chronic pelvic pain are thought to be associated with iatrogenic adenomyosis and/or a chronic inflammatory state created when accumulated blood and mucus are intermittently expelled. Secondary infertility can occur, it is believed, as accumulated fluid and blood interfere with the endocervical and even the endometrial environment and disrupt sperm transport, sperm quality, and embryo implantation. Difficulty in embryo transfer may also occur because of the distortion caused to the endometrial cavity. Many of the isthmoceles that we and others have diagnosed have been in patients undergoing invitro fertilization. The patients are often found to have an accumulation of fluid in the endometrial canal and isthmocele during stimulation for either a fresh or frozen embryo transfer, thus necessitating the cancellation of their cycle.

Treatment

The choice of treatment depends upon the patient’s symptoms and desire for future fertility, but it can include hormonal treatment, hysteroscopic resection, transvaginal repair, a laparoscopic or robot-assisted approach, and hysterectomy.

Little has been published on nonsurgical treatment, but this may be considered for patients whose primary symptoms are bleeding or pain and who desire the least invasive option. In a small observational study of women with an isthmocele and bleeding, symptoms were eliminated with several cycles of oral contraceptive pills (Fertil. Steril. 2006;86: 477-9).

Courtesy of Dr. Kirsten Sasaki

Hysteroscopic isthmocele correction or resection are the surgical techniques most frequently described in the literature, but, as with other surgical approaches, studies are small. Hysteroscopic repair has typically involved the use of electrical energy to desiccate or cauterize abnormal tissue and eliminate the outpouching in which blood and fluid accumulate. Hysteroscopic resection is another technique that has also been championed.

However, for patients who desire future pregnancy, we do not recommend a hysteroscopic approach because it does not reinforce the often-thinning myometrium covering the defect. We are concerned that if this area is simply desiccated or resected, and not reapproximated, the patient will be at greater risk of pregnancy-related complications, including cesarean scar ectopic pregnancy with potential uterine dehiscence.

Laparoscopic repair was first described by Dr. Olivier Donnez, who rightly pointed out that the laparoscopic approach offers an optimal view from above during dissection of the vesico-vaginal space. Dr. Donnez used a CO₂ laser to excise fibrotic tissue, followed by laparoscopic closure (Fertil. Steril. 2008;89:974-80).

We have had success with a laparoscopic approach that uses concomitant hysteroscopy. The vesico-uterine peritoneum is incised over the anterior uterine wall, and the bladder is backfilled so that its boundaries may be identified prior to further dissection. With the area exposed, we perform a hysteroscopy to determine the exact location of the isthmocele. As the hysteroscope enters the thinned out isthmocele, the light will be more visible via laparoscopic visualization.

When performing conventional laparoscopy, the isthmocele is excised with an ultrasonic curved blade. We use this instrument because it has no opposing arm and because it enables precise tissue dissection in multiple planes. With harmonic energy, we can limit tissue dessication and destruction, lowering the risk of future pregnancy-related complications. Monopolar scissors are best when a robotic approach is used.

Once the isthmocele is resected, the clean edges are sutured together in two layers. The first layer is sutured in an interrupted mattress-style fashion, to prevent tissue strangulation and necrosis. We use a monofilament nonbarbed delayed-absorbable 3-0 PDS suture on a CT-1 needle – a choice that limits tissue trauma and postoperative inflammation.

Courtesy of Dr. Kirsten Sasaki

Sutures are initially placed at each angle with one or two sutures placed between. These sutures must be placed deep to close the bottom of the defect. A second layer of suture is then placed to imbricate over the initial layer of closure. We utilize 3-0 PDS in a running or mattress style, or a running 3-0 V-Loc suture. Our patients return after 1-3 months for a postoperative image, and are instructed to wait at least 3 months after surgery before attempting conception.

In our experience, of more than 10 patients, symptoms ceased in all patients whose surgery was performed for the indication of abnormal uterine bleeding. The follow-up on our series of patients who underwent the procedure for secondary infertility is ongoing, but the preliminary results are very positive, with resolution of intrauterine fluid in all of the patients, as well as several successful pregnancy outcomes.

A recent systematic review of minimally invasive therapy for symptoms related to an isthmocele shows good outcomes across the 12 included studies but does not offer evidence to favor one treatment over another. The studies show significant reductions in abnormal uterine bleeding and pain, as well as a high rate of satisfaction in most patients after hysteroscopic niche resection or vaginal or laparoscopic niche repair, with a low complication rate (BJOG 2014;121:145-6).

Pregnancies were reported after treatment, but sample sizes and follow-up were insufficient to draw conclusions on pregnancy and delivery outcomes, according to the review. As the reviewers wrote, following patients through their next delivery in larger, higher-quality studies will help provide more guidance for selecting the best isthmocele treatments and implementing these treatments into practice.

Dr. Sasaki reported having no financial disclosures relevant to this Master Class.

In recent years, uterine isthmocele has increasingly been included as part of the differential in women with a history of a cesarean section who present with postmenstrual bleeding, pelvic pain, or secondary infertility.

The defect appears as a fluid-filled, pouch-like abnormality in the anterior uterine wall at the site of a prior cesarean section. The best method for diagnosis is usually a saline-infused sonogram. It can be treated in various ways, depending on the patient’s symptoms and desire for future fertility. Although we have treated isthmoceles with hysteroscopic desiccation, or resection, our best success has occurred with laparoscopic resection and reapproximation of normal tissue in a small series of patients.

There is no standard definition of the defect that fully describes its size, depth, and other characteristics. Many words and phrases have been used to describe the defect: It is commonly referred to as an isthmocele, because of its usual location at the uterine isthmus, but others have referred to it as a cesarean scar defect or niche, as the defect may be found at the endocervical canal or in the lower uterine segment. In any case, while diagnoses appear to be increasing, the incidence of the defect is unknown.

More research on risk factors and treatment is needed, but the literature, as well as our own experience, has demonstrated that this treatable defect should be considered in the differential diagnosis for women who have undergone cesarean section and subsequently have abnormal bleeding or staining, pelvic pain, or secondary infertility, especially when fluid is clearly visible in the cesarean section defect.

Diagnosis, symptoms

An isthmocele forms in the first place, it is thought, after an incision scar forms and causes retraction and dilation in the thinner, lower segment of the anterior wall and a thickening in the upper portion. There is a deficient scar, in other words, with disparate wound healing on the sides of the incision site.

The defect and its consequences were described in 1995 by Dr. Hugh Morris, who studied hysterectomy specimens in 51 women with a history of cesarean section (in most cases, more than one). Dr. Morris concluded that scar tissue in these patients contributed to significant pathological changes and anatomical abnormalities that, in turn, gave rise to a variety of clinical symptoms including menorrhagia, dysmenorrhea, dyspareunia, and lower abdominal pain refractory to medical management.

Distortion and widening of the lower uterine segment and “free” red blood cells in endometrial stroma of the scar were the most frequently identified pathological changes, followed by fragmentation and breakdown of the endometrium of the scar, and iatrogenic adenomyosis (Int. J. Gynecol. Pathol.1995;14:16-20).

Several small reports and case series published in the late 1990s offered additional support for a cause-and-effect correlation between cesarean scar defects and abnormal vaginal bleeding. Several years later, the link was strengthened as more investigators reported connections between the defects and various symptoms. These reports were followed by published comparisons of imaging techniques for the diagnosis of isthmoceles.

Diagnosis of the defects can be made with transvaginal ultrasound (TVUS), saline infused sonohysterogram (SIS), hysterosalpingogram, hysteroscopy, and magnetic resonance imaging (MRI). With any modality, imaging is best performed in the early proliferative phase, right after the menstrual cycle has ended.

Courtesy of Dr. Kirsten Sasaki

Comparisons of unenhanced TVUS and SIS – both of which may be easily performed in the office and at a much lower cost than MRI – have shown the latter technique to be superior for evaluating isthmoceles. Distension of the endometrial cavity makes the borders of the defects easier to delineate, which enables detection of more subtle defects and improves our ability to measure the size of defects.

This advantage was described by in 2010 by Dr. O. Vikhareva Osser and colleagues, who performed both TVUS and SIS in 108 women with a history of one or more cesarean sections. They identified more scar defects with SIS than with TVUS (Ultrasound Obstet. Gynecol. 2010;35:75-83).

Another benefit of SIS over TVUS and hysterosalpingogram is that one can measure the thickness of the remaining myometrium overlying the isthmocele, which is especially important knowledge for patients considering another pregnancy. As a result, we have relied on this technique to diagnose every case within our practice. I will perform SIS in a patient who has a history of one or multiple cesarean sections and symptoms of abnormal bleeding, pelvic pain, or secondary infertility as part of the basic work-up.

Similarly, an observational prospective cohort study of 225 women who had undergone a cesarean section 6-12 months prior compared TVUS and gel-infused sonohysterogram (GIS), and found that the prevalence of a niche – defined as an anechoic area at the site of the cesarean scar, with a depth of at least 1 mm on GIS – was 24% with TVUS and 56% with GIS (Ultrasound Obstet. Gynecol. 2011;37:93-9).

The abnormal bleeding is often described by patients as spotting or bleeding that continues for days or weeks after menstrual flow has ended; it is believed to result from an accumulation of blood in the defect and a lack of coordinated muscle contractions, which leads to continued accumulation of blood and menstrual debris. Dysmenorrhea and chronic pelvic pain are thought to be associated with iatrogenic adenomyosis and/or a chronic inflammatory state created when accumulated blood and mucus are intermittently expelled. Secondary infertility can occur, it is believed, as accumulated fluid and blood interfere with the endocervical and even the endometrial environment and disrupt sperm transport, sperm quality, and embryo implantation. Difficulty in embryo transfer may also occur because of the distortion caused to the endometrial cavity. Many of the isthmoceles that we and others have diagnosed have been in patients undergoing invitro fertilization. The patients are often found to have an accumulation of fluid in the endometrial canal and isthmocele during stimulation for either a fresh or frozen embryo transfer, thus necessitating the cancellation of their cycle.

Treatment

The choice of treatment depends upon the patient’s symptoms and desire for future fertility, but it can include hormonal treatment, hysteroscopic resection, transvaginal repair, a laparoscopic or robot-assisted approach, and hysterectomy.

Little has been published on nonsurgical treatment, but this may be considered for patients whose primary symptoms are bleeding or pain and who desire the least invasive option. In a small observational study of women with an isthmocele and bleeding, symptoms were eliminated with several cycles of oral contraceptive pills (Fertil. Steril. 2006;86: 477-9).

Courtesy of Dr. Kirsten Sasaki

Hysteroscopic isthmocele correction or resection are the surgical techniques most frequently described in the literature, but, as with other surgical approaches, studies are small. Hysteroscopic repair has typically involved the use of electrical energy to desiccate or cauterize abnormal tissue and eliminate the outpouching in which blood and fluid accumulate. Hysteroscopic resection is another technique that has also been championed.

However, for patients who desire future pregnancy, we do not recommend a hysteroscopic approach because it does not reinforce the often-thinning myometrium covering the defect. We are concerned that if this area is simply desiccated or resected, and not reapproximated, the patient will be at greater risk of pregnancy-related complications, including cesarean scar ectopic pregnancy with potential uterine dehiscence.

Laparoscopic repair was first described by Dr. Olivier Donnez, who rightly pointed out that the laparoscopic approach offers an optimal view from above during dissection of the vesico-vaginal space. Dr. Donnez used a CO₂ laser to excise fibrotic tissue, followed by laparoscopic closure (Fertil. Steril. 2008;89:974-80).

We have had success with a laparoscopic approach that uses concomitant hysteroscopy. The vesico-uterine peritoneum is incised over the anterior uterine wall, and the bladder is backfilled so that its boundaries may be identified prior to further dissection. With the area exposed, we perform a hysteroscopy to determine the exact location of the isthmocele. As the hysteroscope enters the thinned out isthmocele, the light will be more visible via laparoscopic visualization.

When performing conventional laparoscopy, the isthmocele is excised with an ultrasonic curved blade. We use this instrument because it has no opposing arm and because it enables precise tissue dissection in multiple planes. With harmonic energy, we can limit tissue dessication and destruction, lowering the risk of future pregnancy-related complications. Monopolar scissors are best when a robotic approach is used.

Once the isthmocele is resected, the clean edges are sutured together in two layers. The first layer is sutured in an interrupted mattress-style fashion, to prevent tissue strangulation and necrosis. We use a monofilament nonbarbed delayed-absorbable 3-0 PDS suture on a CT-1 needle – a choice that limits tissue trauma and postoperative inflammation.

Courtesy of Dr. Kirsten Sasaki

Sutures are initially placed at each angle with one or two sutures placed between. These sutures must be placed deep to close the bottom of the defect. A second layer of suture is then placed to imbricate over the initial layer of closure. We utilize 3-0 PDS in a running or mattress style, or a running 3-0 V-Loc suture. Our patients return after 1-3 months for a postoperative image, and are instructed to wait at least 3 months after surgery before attempting conception.

In our experience, of more than 10 patients, symptoms ceased in all patients whose surgery was performed for the indication of abnormal uterine bleeding. The follow-up on our series of patients who underwent the procedure for secondary infertility is ongoing, but the preliminary results are very positive, with resolution of intrauterine fluid in all of the patients, as well as several successful pregnancy outcomes.

A recent systematic review of minimally invasive therapy for symptoms related to an isthmocele shows good outcomes across the 12 included studies but does not offer evidence to favor one treatment over another. The studies show significant reductions in abnormal uterine bleeding and pain, as well as a high rate of satisfaction in most patients after hysteroscopic niche resection or vaginal or laparoscopic niche repair, with a low complication rate (BJOG 2014;121:145-6).

Pregnancies were reported after treatment, but sample sizes and follow-up were insufficient to draw conclusions on pregnancy and delivery outcomes, according to the review. As the reviewers wrote, following patients through their next delivery in larger, higher-quality studies will help provide more guidance for selecting the best isthmocele treatments and implementing these treatments into practice.

Dr. Sasaki reported having no financial disclosures relevant to this Master Class.

Recently, after a long day at the hospital, I stopped at the grocery store to pick up something for a quick dinner. I drifted to the frozen food case in the organic food section, but pulled up short when I saw empty shelves. A paper sign announced that Amy’s Kitchen, a manufacturer of organic and natural frozen foods, had become the latest company to recall its products because of concern about Listeria monocytogenes contamination.

According to information posted on the Food and Drug Administration website, this facultative, anaerobic gram-positive bacillus has been the impetus behind 10 national recalls of food products between April 1 and May 8, 2015 alone. Implicated food products have ranged from gourmet ice cream to soybean sprouts to frozen vegetables. Unlike some other bacterial causes of food-borne illness, Listeria organisms can thrive at cold temperatures. Historically, outbreaks of disease have been linked to a variety of foods, including raw produce, contaminated ready-to-eat foods such as deli meats and prepared salads, and unpasteurized milk and milk products.

Clinical manifestations of listeriosis range from febrile gastroenteritis to bacteremia and meningitis, with severe disease seen primarily in immunocompromised individuals and adults 65 and older.

Pregnant women are especially susceptible, with incidence rates 13 times higher than in the general population. Probably as a result of food choices, Hispanic women are disproportionately affected, with rates up to 24 times higher. Maternal infection may be asymptomatic or may manifest with flulike symptoms that include fever, myalgias, headache, and backache, with or without a preceding diarrhea illness. Even mild maternal illness may result in adverse pregnancy outcomes such as fetal loss, premature labor, and severe neonatal infection.

While medical students and residents are still taught to think of Listeria infection as one of the “big three” causes of neonatal sepsis along with group B streptococcus and Escherichia coli, many pediatricians have never seen a case of this rare, but potentially devastating disease. As with group B streptococcus, both early-onset and late-onset disease occur. Sepsis is the most common presentation of disease in the first week of life, while meningitis predominates in late-onset disease. Pneumonia and myocarditis are occasionally seen. Granulomatosis infantisepticum is an uncommon manifestation of severe, disseminated Listeria infection. Granuloma can occur in nearly every organ, although involvement of the liver and skin is most common.

In 2002, investigators from the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists surveyed more than 400 pregnant women from across the United States about their knowledge of the transmission, risk factors, symptoms, and prevention of listeriosis (Infect. Dis. Obstet. Gyn. 2005;13:11-15). A year later, the Minnesota Department of Health surveyed an additional 286 pregnant women from their state using the same survey instrument.

More than 80% of survey respondents had never heard of the disease, and knowledge about prevention strategies was therefore predictably limited. Only 33% of respondents in the national survey and 17% of respondents in the Minnesota survey knew, for example, that infection could be prevented by avoiding delicatessen meats and soft cheeses. Investigators concluded that “timely and appropriate education” of pregnant women about listeriosis could reduce cases of perinatal infection.

Data from the CDC suggest we have more work to do. The Listeria Initiative is an enhanced national surveillance system that collects laboratory, clinical, and food exposure data about listeriosis cases in the United States. Between 2009 and 2011, 14% of the 1,651 invasive Listeria infections reported were classified as pregnancy associated. Morbidity and mortality were significant, with 40 fetal losses and 6 neonatal deaths (MMWR 2013;62:448-52).

The CDC offers some common sense tips for preventing listeriosis and other food-borne illness. Raw fruits and vegetables should be thoroughly rinsed with tap water and dried with a clean cloth or paper towel before being eaten or cooked. Even foods that are typically peeled first should be washed, and firm produce, such as cantaloupe, should be scrubbed with a produce brush to reduce surface contamination. Uncooked meats and poultry should never come in contact with other food. Hands, knives, cutting boards, and other food preparation surfaces should be washed thoroughly after uncooked food is handled.

Pregnant women and others at increased risk for listeriosis should not eat hot dogs or deli meats unless they are cooked to steaming. Soft cheeses, including feta, brie, Camembert, queso blanco, or anything blue veined, should be avoided unless the label clearly states that the product has been made with pasteurized milk. Even then, it might not be safe. Pasteurized Mexican-style cheeses, such as queso fresco, have been linked to Listeria infections, likely as a result of contamination during the cheese-making process.

Physicians should be prepared to field calls from concerned parents who believe their children may have consumed a product potentially contaminated with Listeria. In general, someone who has eaten a recalled food product but has no symptoms doesn’t need a laboratory evaluation or treatment. Screening blood cultures is not indicated, and routine tests such as a complete blood count are unlikely to be helpful. Instead, patients should be counseled about the symptoms of listeriosis and undergo prompt evaluation if any develop within 2 months of exposure. The typical interval between exposure and the development of symptoms is 1 day to 3 weeks, but may be as long as 70 days.

Although Listeria infection may result in gastrointestinal symptoms, stool cultures are not recommended for diagnosis. According to the CDC, ingestion of food contaminated with Listeria occurs frequently because the organisms are commonly found in the environment. Although uncommon, intermittent fecal carriage and shedding have been observed in asymptomatic individuals.

Back at the grocery, I sighed and resigned myself to a grilled cheese sandwich for dinner. I turned and saw another woman in the aisle stop and read the sign on the freezer case.

“It’s a little scary,” she said with a sigh. “It seems like there is another recall every week, and I’m wondering what’s safe to eat.”

The parents of our patients may have similar questions. Although the Food and Drug Administration offers detailed guidance for food manufacturers about reducing Listeria contamination, perfect compliance wouldn’t eliminate the risk for consumers because L. monocytogenes is widespread in the environment. The organisms are found in water, soil, sewage, and decaying vegetation, and can be isolated from a variety of animals. Fresh fruits and vegetables are “healthy” choices as long as they are handled and prepared appropriately. Conversely, unpasteurized milk and milk products can never be considered safe.

That’s food for thought.

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Kosair Children’s Hospital, also in Louisville. She had no relevant financial disclosures. 

Recently, after a long day at the hospital, I stopped at the grocery store to pick up something for a quick dinner. I drifted to the frozen food case in the organic food section, but pulled up short when I saw empty shelves. A paper sign announced that Amy’s Kitchen, a manufacturer of organic and natural frozen foods, had become the latest company to recall its products because of concern about Listeria monocytogenes contamination.

According to information posted on the Food and Drug Administration website, this facultative, anaerobic gram-positive bacillus has been the impetus behind 10 national recalls of food products between April 1 and May 8, 2015 alone. Implicated food products have ranged from gourmet ice cream to soybean sprouts to frozen vegetables. Unlike some other bacterial causes of food-borne illness, Listeria organisms can thrive at cold temperatures. Historically, outbreaks of disease have been linked to a variety of foods, including raw produce, contaminated ready-to-eat foods such as deli meats and prepared salads, and unpasteurized milk and milk products.

Clinical manifestations of listeriosis range from febrile gastroenteritis to bacteremia and meningitis, with severe disease seen primarily in immunocompromised individuals and adults 65 and older.

Pregnant women are especially susceptible, with incidence rates 13 times higher than in the general population. Probably as a result of food choices, Hispanic women are disproportionately affected, with rates up to 24 times higher. Maternal infection may be asymptomatic or may manifest with flulike symptoms that include fever, myalgias, headache, and backache, with or without a preceding diarrhea illness. Even mild maternal illness may result in adverse pregnancy outcomes such as fetal loss, premature labor, and severe neonatal infection.

While medical students and residents are still taught to think of Listeria infection as one of the “big three” causes of neonatal sepsis along with group B streptococcus and Escherichia coli, many pediatricians have never seen a case of this rare, but potentially devastating disease. As with group B streptococcus, both early-onset and late-onset disease occur. Sepsis is the most common presentation of disease in the first week of life, while meningitis predominates in late-onset disease. Pneumonia and myocarditis are occasionally seen. Granulomatosis infantisepticum is an uncommon manifestation of severe, disseminated Listeria infection. Granuloma can occur in nearly every organ, although involvement of the liver and skin is most common.

In 2002, investigators from the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists surveyed more than 400 pregnant women from across the United States about their knowledge of the transmission, risk factors, symptoms, and prevention of listeriosis (Infect. Dis. Obstet. Gyn. 2005;13:11-15). A year later, the Minnesota Department of Health surveyed an additional 286 pregnant women from their state using the same survey instrument.

More than 80% of survey respondents had never heard of the disease, and knowledge about prevention strategies was therefore predictably limited. Only 33% of respondents in the national survey and 17% of respondents in the Minnesota survey knew, for example, that infection could be prevented by avoiding delicatessen meats and soft cheeses. Investigators concluded that “timely and appropriate education” of pregnant women about listeriosis could reduce cases of perinatal infection.

Data from the CDC suggest we have more work to do. The Listeria Initiative is an enhanced national surveillance system that collects laboratory, clinical, and food exposure data about listeriosis cases in the United States. Between 2009 and 2011, 14% of the 1,651 invasive Listeria infections reported were classified as pregnancy associated. Morbidity and mortality were significant, with 40 fetal losses and 6 neonatal deaths (MMWR 2013;62:448-52).

The CDC offers some common sense tips for preventing listeriosis and other food-borne illness. Raw fruits and vegetables should be thoroughly rinsed with tap water and dried with a clean cloth or paper towel before being eaten or cooked. Even foods that are typically peeled first should be washed, and firm produce, such as cantaloupe, should be scrubbed with a produce brush to reduce surface contamination. Uncooked meats and poultry should never come in contact with other food. Hands, knives, cutting boards, and other food preparation surfaces should be washed thoroughly after uncooked food is handled.

Pregnant women and others at increased risk for listeriosis should not eat hot dogs or deli meats unless they are cooked to steaming. Soft cheeses, including feta, brie, Camembert, queso blanco, or anything blue veined, should be avoided unless the label clearly states that the product has been made with pasteurized milk. Even then, it might not be safe. Pasteurized Mexican-style cheeses, such as queso fresco, have been linked to Listeria infections, likely as a result of contamination during the cheese-making process.

Physicians should be prepared to field calls from concerned parents who believe their children may have consumed a product potentially contaminated with Listeria. In general, someone who has eaten a recalled food product but has no symptoms doesn’t need a laboratory evaluation or treatment. Screening blood cultures is not indicated, and routine tests such as a complete blood count are unlikely to be helpful. Instead, patients should be counseled about the symptoms of listeriosis and undergo prompt evaluation if any develop within 2 months of exposure. The typical interval between exposure and the development of symptoms is 1 day to 3 weeks, but may be as long as 70 days.

Although Listeria infection may result in gastrointestinal symptoms, stool cultures are not recommended for diagnosis. According to the CDC, ingestion of food contaminated with Listeria occurs frequently because the organisms are commonly found in the environment. Although uncommon, intermittent fecal carriage and shedding have been observed in asymptomatic individuals.

Back at the grocery, I sighed and resigned myself to a grilled cheese sandwich for dinner. I turned and saw another woman in the aisle stop and read the sign on the freezer case.

“It’s a little scary,” she said with a sigh. “It seems like there is another recall every week, and I’m wondering what’s safe to eat.”

The parents of our patients may have similar questions. Although the Food and Drug Administration offers detailed guidance for food manufacturers about reducing Listeria contamination, perfect compliance wouldn’t eliminate the risk for consumers because L. monocytogenes is widespread in the environment. The organisms are found in water, soil, sewage, and decaying vegetation, and can be isolated from a variety of animals. Fresh fruits and vegetables are “healthy” choices as long as they are handled and prepared appropriately. Conversely, unpasteurized milk and milk products can never be considered safe.

That’s food for thought.

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Kosair Children’s Hospital, also in Louisville. She had no relevant financial disclosures. 

Recently, after a long day at the hospital, I stopped at the grocery store to pick up something for a quick dinner. I drifted to the frozen food case in the organic food section, but pulled up short when I saw empty shelves. A paper sign announced that Amy’s Kitchen, a manufacturer of organic and natural frozen foods, had become the latest company to recall its products because of concern about Listeria monocytogenes contamination.

According to information posted on the Food and Drug Administration website, this facultative, anaerobic gram-positive bacillus has been the impetus behind 10 national recalls of food products between April 1 and May 8, 2015 alone. Implicated food products have ranged from gourmet ice cream to soybean sprouts to frozen vegetables. Unlike some other bacterial causes of food-borne illness, Listeria organisms can thrive at cold temperatures. Historically, outbreaks of disease have been linked to a variety of foods, including raw produce, contaminated ready-to-eat foods such as deli meats and prepared salads, and unpasteurized milk and milk products.

Clinical manifestations of listeriosis range from febrile gastroenteritis to bacteremia and meningitis, with severe disease seen primarily in immunocompromised individuals and adults 65 and older.

Pregnant women are especially susceptible, with incidence rates 13 times higher than in the general population. Probably as a result of food choices, Hispanic women are disproportionately affected, with rates up to 24 times higher. Maternal infection may be asymptomatic or may manifest with flulike symptoms that include fever, myalgias, headache, and backache, with or without a preceding diarrhea illness. Even mild maternal illness may result in adverse pregnancy outcomes such as fetal loss, premature labor, and severe neonatal infection.

While medical students and residents are still taught to think of Listeria infection as one of the “big three” causes of neonatal sepsis along with group B streptococcus and Escherichia coli, many pediatricians have never seen a case of this rare, but potentially devastating disease. As with group B streptococcus, both early-onset and late-onset disease occur. Sepsis is the most common presentation of disease in the first week of life, while meningitis predominates in late-onset disease. Pneumonia and myocarditis are occasionally seen. Granulomatosis infantisepticum is an uncommon manifestation of severe, disseminated Listeria infection. Granuloma can occur in nearly every organ, although involvement of the liver and skin is most common.

In 2002, investigators from the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists surveyed more than 400 pregnant women from across the United States about their knowledge of the transmission, risk factors, symptoms, and prevention of listeriosis (Infect. Dis. Obstet. Gyn. 2005;13:11-15). A year later, the Minnesota Department of Health surveyed an additional 286 pregnant women from their state using the same survey instrument.

More than 80% of survey respondents had never heard of the disease, and knowledge about prevention strategies was therefore predictably limited. Only 33% of respondents in the national survey and 17% of respondents in the Minnesota survey knew, for example, that infection could be prevented by avoiding delicatessen meats and soft cheeses. Investigators concluded that “timely and appropriate education” of pregnant women about listeriosis could reduce cases of perinatal infection.

Data from the CDC suggest we have more work to do. The Listeria Initiative is an enhanced national surveillance system that collects laboratory, clinical, and food exposure data about listeriosis cases in the United States. Between 2009 and 2011, 14% of the 1,651 invasive Listeria infections reported were classified as pregnancy associated. Morbidity and mortality were significant, with 40 fetal losses and 6 neonatal deaths (MMWR 2013;62:448-52).

The CDC offers some common sense tips for preventing listeriosis and other food-borne illness. Raw fruits and vegetables should be thoroughly rinsed with tap water and dried with a clean cloth or paper towel before being eaten or cooked. Even foods that are typically peeled first should be washed, and firm produce, such as cantaloupe, should be scrubbed with a produce brush to reduce surface contamination. Uncooked meats and poultry should never come in contact with other food. Hands, knives, cutting boards, and other food preparation surfaces should be washed thoroughly after uncooked food is handled.

Pregnant women and others at increased risk for listeriosis should not eat hot dogs or deli meats unless they are cooked to steaming. Soft cheeses, including feta, brie, Camembert, queso blanco, or anything blue veined, should be avoided unless the label clearly states that the product has been made with pasteurized milk. Even then, it might not be safe. Pasteurized Mexican-style cheeses, such as queso fresco, have been linked to Listeria infections, likely as a result of contamination during the cheese-making process.

Physicians should be prepared to field calls from concerned parents who believe their children may have consumed a product potentially contaminated with Listeria. In general, someone who has eaten a recalled food product but has no symptoms doesn’t need a laboratory evaluation or treatment. Screening blood cultures is not indicated, and routine tests such as a complete blood count are unlikely to be helpful. Instead, patients should be counseled about the symptoms of listeriosis and undergo prompt evaluation if any develop within 2 months of exposure. The typical interval between exposure and the development of symptoms is 1 day to 3 weeks, but may be as long as 70 days.

Although Listeria infection may result in gastrointestinal symptoms, stool cultures are not recommended for diagnosis. According to the CDC, ingestion of food contaminated with Listeria occurs frequently because the organisms are commonly found in the environment. Although uncommon, intermittent fecal carriage and shedding have been observed in asymptomatic individuals.

Back at the grocery, I sighed and resigned myself to a grilled cheese sandwich for dinner. I turned and saw another woman in the aisle stop and read the sign on the freezer case.

“It’s a little scary,” she said with a sigh. “It seems like there is another recall every week, and I’m wondering what’s safe to eat.”

The parents of our patients may have similar questions. Although the Food and Drug Administration offers detailed guidance for food manufacturers about reducing Listeria contamination, perfect compliance wouldn’t eliminate the risk for consumers because L. monocytogenes is widespread in the environment. The organisms are found in water, soil, sewage, and decaying vegetation, and can be isolated from a variety of animals. Fresh fruits and vegetables are “healthy” choices as long as they are handled and prepared appropriately. Conversely, unpasteurized milk and milk products can never be considered safe.

That’s food for thought.

Dr. Bryant is a pediatrician specializing in infectious diseases at the University of Louisville (Ky.) and Kosair Children’s Hospital, also in Louisville. She had no relevant financial disclosures. 

Negative pressure wound therapy is a wound management system for chronic open subcutaneous or intra-abdominal wounds. Some popular commercial systems include V.A.C. therapy (KCI, San Antonio) and the Chariker-Jeter wound-sealing kit (Smith and Nephew, London). Within ob.gyn. and gynecologic oncology, they have use in the management of postoperative superficial wound dehiscence from routine surgery and in the management of the open abdomen.

The primary benefit of negative pressure wound therapy (NPWT) is the acceleration of wound healing. Postoperative superficial wound dehiscence can occur as a result of surgical factors such as wound infection and subcutaneous seroma/hematoma or systematic factors such as poor nutrition and wound ischemia.

Acceleration of wound healing results from the design of the NPWT systems. They consist of semipermeable dressings (foam), sealed with an adhesive sheet that is connected to a portable pump. By the application of –50 to –175 mm Hg of continuous or intermittent suction, the edges of the wound are drawn together, and this deforming process promotes tissue remodeling at the cellular level. Other potential benefits of negative pressure are increased blood flow, a decrease in mediators of inflammation, and an increase in collagen organization via changes in wound biochemistry.

An alternative to NPWT would be traditional gauze dressings, which can also be applied in the case of superficial wound dehiscence. These are changed up to three times a day, however, and this can result in significant patient discomfort, caregiver difficulties, and prolonged healing of weeks to months. In contrast, NPWT dressings are changed once every 2-3 days. They are also versatile and can be fit to traditionally shaped abdominal wounds, as well as difficult to dress vulvar and groin wounds (J. Obstet. Gynaecol. Can. 2011;33:1031-7).

In a series of 27 gynecologic oncology patients in whom NPWT was employed after primary wound–healing failure, there was a 96% reduction in the size of the wounds with a median number of therapy days of 32 (range, 3-88). The majority of these patients were also managed as outpatients without complication (Gynecol. Oncol. 2004;92:586-91).

There are some contraindications to NPWT that should be considered. The major, and perhaps most common, is an ongoing wound infection.

A wound that needs to be evaluated at least daily to assess the response to antibiotic therapy or need for debridement should not be managed with NPWT until the wound is deemed stable. There should be no devitalized tissue present in the wound upon application of the NPWT. If any necrotic tissue is present, then wound debridement is warranted until only well-vascularized tissue remains.

Another contraindication is the presence of malignant tissue in the wound. Negative pressure can promote this tissue growth and lead to chronic nonhealing. Other considerations would include adhesive allergies and fragile skin due to chronic steroid use or collagen vascular disorders, as NPWT can lead to skin necrosis.

Finally, the involvement of vital organs, such as exposed bowel, is a contraindication to the NPWT systems, as constant suction can promote fistula formation or hemorrhage. However, in the setting of an open abdomen after trauma surgery, there has been the development of intra-abdominal wound management systems that may be appropriate.

Although rare in obstetrics, gynecology, and gynecologic oncology, delayed abdominal closure may be necessary. This can occur after reoperation for bowel injury, in cases where bowel wall edema and increased intra-abdominal pressure preclude closure, or in cases of massive hemorrhage (for example, ruptured ectopic pregnancy) where patient instability necessitates rapid termination of the surgical case. These wounds can be managed with temporary abdominal closure techniques such as retention sutures, a Bogota bag, or loose packing (World. J. Surg. 2015; 39: 912-25).

The negative pressure systems developed for these instances are the V.A.C. abdominal dressing (KCI), Renasys NPWT (Smith and Nephew), and ABThera open abdomen negative pressure therapy (KCI). They consist of a perforated plastic sheet with foam attachments that is placed directly in the abdomen to cover the intestine. This is then covered with an adhesive dressing that is cut to accommodate the suction attachment for the negative pressure pump. This setup is easily applied and taken down, and therefore facilitates frequent abdominal washouts until true facial closure can be achieved.

There are many benefits to NPWT for the management of superficial and deep wound dehiscence in the ob.gyn. or gynecologic oncology patient. NPWT should be considered primarily with any surgical wound healing by secondary intention.

Dr. Doll is a third-year fellow in gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the university. The authors reported having no relevant financial disclosures.

Negative pressure wound therapy is a wound management system for chronic open subcutaneous or intra-abdominal wounds. Some popular commercial systems include V.A.C. therapy (KCI, San Antonio) and the Chariker-Jeter wound-sealing kit (Smith and Nephew, London). Within ob.gyn. and gynecologic oncology, they have use in the management of postoperative superficial wound dehiscence from routine surgery and in the management of the open abdomen.

The primary benefit of negative pressure wound therapy (NPWT) is the acceleration of wound healing. Postoperative superficial wound dehiscence can occur as a result of surgical factors such as wound infection and subcutaneous seroma/hematoma or systematic factors such as poor nutrition and wound ischemia.

Acceleration of wound healing results from the design of the NPWT systems. They consist of semipermeable dressings (foam), sealed with an adhesive sheet that is connected to a portable pump. By the application of –50 to –175 mm Hg of continuous or intermittent suction, the edges of the wound are drawn together, and this deforming process promotes tissue remodeling at the cellular level. Other potential benefits of negative pressure are increased blood flow, a decrease in mediators of inflammation, and an increase in collagen organization via changes in wound biochemistry.

An alternative to NPWT would be traditional gauze dressings, which can also be applied in the case of superficial wound dehiscence. These are changed up to three times a day, however, and this can result in significant patient discomfort, caregiver difficulties, and prolonged healing of weeks to months. In contrast, NPWT dressings are changed once every 2-3 days. They are also versatile and can be fit to traditionally shaped abdominal wounds, as well as difficult to dress vulvar and groin wounds (J. Obstet. Gynaecol. Can. 2011;33:1031-7).

In a series of 27 gynecologic oncology patients in whom NPWT was employed after primary wound–healing failure, there was a 96% reduction in the size of the wounds with a median number of therapy days of 32 (range, 3-88). The majority of these patients were also managed as outpatients without complication (Gynecol. Oncol. 2004;92:586-91).

There are some contraindications to NPWT that should be considered. The major, and perhaps most common, is an ongoing wound infection.

A wound that needs to be evaluated at least daily to assess the response to antibiotic therapy or need for debridement should not be managed with NPWT until the wound is deemed stable. There should be no devitalized tissue present in the wound upon application of the NPWT. If any necrotic tissue is present, then wound debridement is warranted until only well-vascularized tissue remains.

Another contraindication is the presence of malignant tissue in the wound. Negative pressure can promote this tissue growth and lead to chronic nonhealing. Other considerations would include adhesive allergies and fragile skin due to chronic steroid use or collagen vascular disorders, as NPWT can lead to skin necrosis.

Finally, the involvement of vital organs, such as exposed bowel, is a contraindication to the NPWT systems, as constant suction can promote fistula formation or hemorrhage. However, in the setting of an open abdomen after trauma surgery, there has been the development of intra-abdominal wound management systems that may be appropriate.

Although rare in obstetrics, gynecology, and gynecologic oncology, delayed abdominal closure may be necessary. This can occur after reoperation for bowel injury, in cases where bowel wall edema and increased intra-abdominal pressure preclude closure, or in cases of massive hemorrhage (for example, ruptured ectopic pregnancy) where patient instability necessitates rapid termination of the surgical case. These wounds can be managed with temporary abdominal closure techniques such as retention sutures, a Bogota bag, or loose packing (World. J. Surg. 2015; 39: 912-25).

The negative pressure systems developed for these instances are the V.A.C. abdominal dressing (KCI), Renasys NPWT (Smith and Nephew), and ABThera open abdomen negative pressure therapy (KCI). They consist of a perforated plastic sheet with foam attachments that is placed directly in the abdomen to cover the intestine. This is then covered with an adhesive dressing that is cut to accommodate the suction attachment for the negative pressure pump. This setup is easily applied and taken down, and therefore facilitates frequent abdominal washouts until true facial closure can be achieved.

There are many benefits to NPWT for the management of superficial and deep wound dehiscence in the ob.gyn. or gynecologic oncology patient. NPWT should be considered primarily with any surgical wound healing by secondary intention.

Dr. Doll is a third-year fellow in gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the university. The authors reported having no relevant financial disclosures.

Negative pressure wound therapy is a wound management system for chronic open subcutaneous or intra-abdominal wounds. Some popular commercial systems include V.A.C. therapy (KCI, San Antonio) and the Chariker-Jeter wound-sealing kit (Smith and Nephew, London). Within ob.gyn. and gynecologic oncology, they have use in the management of postoperative superficial wound dehiscence from routine surgery and in the management of the open abdomen.

The primary benefit of negative pressure wound therapy (NPWT) is the acceleration of wound healing. Postoperative superficial wound dehiscence can occur as a result of surgical factors such as wound infection and subcutaneous seroma/hematoma or systematic factors such as poor nutrition and wound ischemia.

Acceleration of wound healing results from the design of the NPWT systems. They consist of semipermeable dressings (foam), sealed with an adhesive sheet that is connected to a portable pump. By the application of –50 to –175 mm Hg of continuous or intermittent suction, the edges of the wound are drawn together, and this deforming process promotes tissue remodeling at the cellular level. Other potential benefits of negative pressure are increased blood flow, a decrease in mediators of inflammation, and an increase in collagen organization via changes in wound biochemistry.

An alternative to NPWT would be traditional gauze dressings, which can also be applied in the case of superficial wound dehiscence. These are changed up to three times a day, however, and this can result in significant patient discomfort, caregiver difficulties, and prolonged healing of weeks to months. In contrast, NPWT dressings are changed once every 2-3 days. They are also versatile and can be fit to traditionally shaped abdominal wounds, as well as difficult to dress vulvar and groin wounds (J. Obstet. Gynaecol. Can. 2011;33:1031-7).

In a series of 27 gynecologic oncology patients in whom NPWT was employed after primary wound–healing failure, there was a 96% reduction in the size of the wounds with a median number of therapy days of 32 (range, 3-88). The majority of these patients were also managed as outpatients without complication (Gynecol. Oncol. 2004;92:586-91).

There are some contraindications to NPWT that should be considered. The major, and perhaps most common, is an ongoing wound infection.

A wound that needs to be evaluated at least daily to assess the response to antibiotic therapy or need for debridement should not be managed with NPWT until the wound is deemed stable. There should be no devitalized tissue present in the wound upon application of the NPWT. If any necrotic tissue is present, then wound debridement is warranted until only well-vascularized tissue remains.

Another contraindication is the presence of malignant tissue in the wound. Negative pressure can promote this tissue growth and lead to chronic nonhealing. Other considerations would include adhesive allergies and fragile skin due to chronic steroid use or collagen vascular disorders, as NPWT can lead to skin necrosis.

Finally, the involvement of vital organs, such as exposed bowel, is a contraindication to the NPWT systems, as constant suction can promote fistula formation or hemorrhage. However, in the setting of an open abdomen after trauma surgery, there has been the development of intra-abdominal wound management systems that may be appropriate.

Although rare in obstetrics, gynecology, and gynecologic oncology, delayed abdominal closure may be necessary. This can occur after reoperation for bowel injury, in cases where bowel wall edema and increased intra-abdominal pressure preclude closure, or in cases of massive hemorrhage (for example, ruptured ectopic pregnancy) where patient instability necessitates rapid termination of the surgical case. These wounds can be managed with temporary abdominal closure techniques such as retention sutures, a Bogota bag, or loose packing (World. J. Surg. 2015; 39: 912-25).

The negative pressure systems developed for these instances are the V.A.C. abdominal dressing (KCI), Renasys NPWT (Smith and Nephew), and ABThera open abdomen negative pressure therapy (KCI). They consist of a perforated plastic sheet with foam attachments that is placed directly in the abdomen to cover the intestine. This is then covered with an adhesive dressing that is cut to accommodate the suction attachment for the negative pressure pump. This setup is easily applied and taken down, and therefore facilitates frequent abdominal washouts until true facial closure can be achieved.

There are many benefits to NPWT for the management of superficial and deep wound dehiscence in the ob.gyn. or gynecologic oncology patient. NPWT should be considered primarily with any surgical wound healing by secondary intention.

Dr. Doll is a third-year fellow in gynecologic oncology at the University of North Carolina at Chapel Hill. Dr. Gehrig is professor and director of gynecologic oncology at the university. The authors reported having no relevant financial disclosures.

The number of parents asking their pediatricians to stray from the recommended immunization schedule by spreading out the vaccines is increasing, and so is the number of pediatricians who are agreeing to follow these spaced-out schedules.

One of the two reasons most often given by pediatricians for agreeing to the less than optimal immunization schedules is that by showing a willingness to compromise, that physician may be helping to build a trusting relationship with these families. The other reason is a concern – let’s be honest and call it a fear – that a dissatisfied family will move its care to another physician/provider.

When we scratch the surface of these two rationales, neither seems to make much sense. The conflict over immunization spacing comes to a head at the 2-month well-child visit recommended call for six injections. If the infant has had an unremarkable neonatal course, there may not have been any situation in which the physician was forced to demonstrate her trustworthiness. As long as she has dressed professionally, showed up on time for appointments, washed her hands, and appeared genuinely interested in the child’s well-being, that’s about all she has had to do.

The physician may give the impression that she can be trusted, but real trust is usually something that must accumulate over time, in monthly – or more likely yearly – increments. Occasionally a crisis allows the physician to behave so heroically that her route to a trusting relationship is compressed to just a few hours, but fortunately these crises are rare.

Does agreeing to an unnecessary and unsubstantiated diversion from the recommended immunization schedule play a role in trust building? It may signal that the physician is willing to compromise, which in some situations may not be a bad attribute. For example, the mother who has struggled and failed at breastfeeding her 6 weeks despite everyone’s best efforts will appreciate her pediatrician’s willingness to compromise. But should compromise of scientifically validated practices really be one of the cornerstones of a physician-patient relationship?

I have never had a family request that the immunization schedule be spread out for their second child because they have seen for themselves that the process is not what they have feared. I gave all the immunizations myself, and my administration style was quick and matter-of-fact. The problem, of course, is getting hesitant parents up to and over that hurdle of the 2-month visit. Unfortunately, the evidence seems to be that education and extra time and reassurance are of little value in getting them to that point of trust.

The more difficult issue is a physician’s fear that by failing to agree to a spaced-out schedule, she will open a spigot and families will flow out of her practice to other more compromising providers. Is this just an ego thing? No one likes to feel rejected. Will the feared patient exodus seriously depress the physician’s income or will it be merely a trickle that can be ignored? Obviously, the answer varies from community to community. Do families have so many options that they will easily be able to find a provider who is eager to grow his or her practice, and is less concerned about the immunization level of the community? Or, is the pediatrician so busy that a firm adherence to the standard schedule might provide a welcome opportunity to have a more manageable panel size, and at the same time shift the patient mix toward families that don’t require the extra time in fruitless “educational” discussions?

These are questions that don’t seem to be getting asked. What are the numbers? Is the loss of patients just an irrational fear for physicians created by an irrational fear of a small segment of the population? If the physician practices in a group, could her fear of patient loss be eased if the entire group committed itself to following the standard immunization schedule? Are group members discussing this issue among themselves and with their practice managers? Or, is everyone just spacing out?

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at [email protected]. Scan this QR code to read similar articles or go to pediatricnews.com.

The number of parents asking their pediatricians to stray from the recommended immunization schedule by spreading out the vaccines is increasing, and so is the number of pediatricians who are agreeing to follow these spaced-out schedules.

One of the two reasons most often given by pediatricians for agreeing to the less than optimal immunization schedules is that by showing a willingness to compromise, that physician may be helping to build a trusting relationship with these families. The other reason is a concern – let’s be honest and call it a fear – that a dissatisfied family will move its care to another physician/provider.

When we scratch the surface of these two rationales, neither seems to make much sense. The conflict over immunization spacing comes to a head at the 2-month well-child visit recommended call for six injections. If the infant has had an unremarkable neonatal course, there may not have been any situation in which the physician was forced to demonstrate her trustworthiness. As long as she has dressed professionally, showed up on time for appointments, washed her hands, and appeared genuinely interested in the child’s well-being, that’s about all she has had to do.

The physician may give the impression that she can be trusted, but real trust is usually something that must accumulate over time, in monthly – or more likely yearly – increments. Occasionally a crisis allows the physician to behave so heroically that her route to a trusting relationship is compressed to just a few hours, but fortunately these crises are rare.

Does agreeing to an unnecessary and unsubstantiated diversion from the recommended immunization schedule play a role in trust building? It may signal that the physician is willing to compromise, which in some situations may not be a bad attribute. For example, the mother who has struggled and failed at breastfeeding her 6 weeks despite everyone’s best efforts will appreciate her pediatrician’s willingness to compromise. But should compromise of scientifically validated practices really be one of the cornerstones of a physician-patient relationship?

I have never had a family request that the immunization schedule be spread out for their second child because they have seen for themselves that the process is not what they have feared. I gave all the immunizations myself, and my administration style was quick and matter-of-fact. The problem, of course, is getting hesitant parents up to and over that hurdle of the 2-month visit. Unfortunately, the evidence seems to be that education and extra time and reassurance are of little value in getting them to that point of trust.

The more difficult issue is a physician’s fear that by failing to agree to a spaced-out schedule, she will open a spigot and families will flow out of her practice to other more compromising providers. Is this just an ego thing? No one likes to feel rejected. Will the feared patient exodus seriously depress the physician’s income or will it be merely a trickle that can be ignored? Obviously, the answer varies from community to community. Do families have so many options that they will easily be able to find a provider who is eager to grow his or her practice, and is less concerned about the immunization level of the community? Or, is the pediatrician so busy that a firm adherence to the standard schedule might provide a welcome opportunity to have a more manageable panel size, and at the same time shift the patient mix toward families that don’t require the extra time in fruitless “educational” discussions?

These are questions that don’t seem to be getting asked. What are the numbers? Is the loss of patients just an irrational fear for physicians created by an irrational fear of a small segment of the population? If the physician practices in a group, could her fear of patient loss be eased if the entire group committed itself to following the standard immunization schedule? Are group members discussing this issue among themselves and with their practice managers? Or, is everyone just spacing out?

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at [email protected]. Scan this QR code to read similar articles or go to pediatricnews.com.

The number of parents asking their pediatricians to stray from the recommended immunization schedule by spreading out the vaccines is increasing, and so is the number of pediatricians who are agreeing to follow these spaced-out schedules.

One of the two reasons most often given by pediatricians for agreeing to the less than optimal immunization schedules is that by showing a willingness to compromise, that physician may be helping to build a trusting relationship with these families. The other reason is a concern – let’s be honest and call it a fear – that a dissatisfied family will move its care to another physician/provider.

When we scratch the surface of these two rationales, neither seems to make much sense. The conflict over immunization spacing comes to a head at the 2-month well-child visit recommended call for six injections. If the infant has had an unremarkable neonatal course, there may not have been any situation in which the physician was forced to demonstrate her trustworthiness. As long as she has dressed professionally, showed up on time for appointments, washed her hands, and appeared genuinely interested in the child’s well-being, that’s about all she has had to do.

The physician may give the impression that she can be trusted, but real trust is usually something that must accumulate over time, in monthly – or more likely yearly – increments. Occasionally a crisis allows the physician to behave so heroically that her route to a trusting relationship is compressed to just a few hours, but fortunately these crises are rare.

Does agreeing to an unnecessary and unsubstantiated diversion from the recommended immunization schedule play a role in trust building? It may signal that the physician is willing to compromise, which in some situations may not be a bad attribute. For example, the mother who has struggled and failed at breastfeeding her 6 weeks despite everyone’s best efforts will appreciate her pediatrician’s willingness to compromise. But should compromise of scientifically validated practices really be one of the cornerstones of a physician-patient relationship?

I have never had a family request that the immunization schedule be spread out for their second child because they have seen for themselves that the process is not what they have feared. I gave all the immunizations myself, and my administration style was quick and matter-of-fact. The problem, of course, is getting hesitant parents up to and over that hurdle of the 2-month visit. Unfortunately, the evidence seems to be that education and extra time and reassurance are of little value in getting them to that point of trust.

The more difficult issue is a physician’s fear that by failing to agree to a spaced-out schedule, she will open a spigot and families will flow out of her practice to other more compromising providers. Is this just an ego thing? No one likes to feel rejected. Will the feared patient exodus seriously depress the physician’s income or will it be merely a trickle that can be ignored? Obviously, the answer varies from community to community. Do families have so many options that they will easily be able to find a provider who is eager to grow his or her practice, and is less concerned about the immunization level of the community? Or, is the pediatrician so busy that a firm adherence to the standard schedule might provide a welcome opportunity to have a more manageable panel size, and at the same time shift the patient mix toward families that don’t require the extra time in fruitless “educational” discussions?

These are questions that don’t seem to be getting asked. What are the numbers? Is the loss of patients just an irrational fear for physicians created by an irrational fear of a small segment of the population? If the physician practices in a group, could her fear of patient loss be eased if the entire group committed itself to following the standard immunization schedule? Are group members discussing this issue among themselves and with their practice managers? Or, is everyone just spacing out?

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “Coping with a Picky Eater.” E-mail him at [email protected]. Scan this QR code to read similar articles or go to pediatricnews.com.

Portulaca oleracea, also known as purslane, has long been used in various traditional medicine systems to relieve pain and edema.¹Portulaca oleracea is a warm-climate annual plant originally found in the Middle East, North Africa, and the Indian subcontinent and now cultivated in the Arabian peninsula; Japan, where it is an abundant garden plant from spring to fall;^2,3 and throughout the world.

The use of P. oleracea, a member of the Portulacaceae family, as a vegetable as well as herbal medicine dates back several centuries.⁴ In modern times, purslane has been found to be rich in antioxidants, particularly omega-3 fatty acids, vitamins C and E, beta-carotene, melatonin, and glutathione, as well as several minerals.^5,6,7 Currently, it is considered one of the top ten most common plants in the world, and one of the most-used medical plants according to the World Health Organization.⁶ It is considered a weed in the United States, but is eaten in many parts of the world.

Antioxidant activity

Using two different assays, Uddin et al. determined in 2012 that P. oleracea cultivars exhibited significant antioxidant activity through various growth stages. In addition, the researchers suggested that purslane could provide multiple minerals as well as antioxidants in the context of nutraceutical products and functional food.⁷ Early this year, Silva et al. studied the antioxidant activity of P. oleracea leaves, flowers, and stems from two different locations in Portugal, with assays revealing significantly greater antioxidant activity in the stems of both samples compared to the leaves and flowers. However, the phenolic extracts of all three plant sections from both samples were found to protect DNA against hydroxyl radicals. The investigators concluded that their findings, particularly related to high antioxidant activity, support the potential benefits of purslane consumption to human health.⁸

A 2014 analysis of 13 collected purslane accessions revealed significant mineral content (particularly potassium, followed by nitrogen, sodium, calcium, magnesium, phosphorus, iron, zinc, and manganese) and showed that antioxidant activity was more strongly associated with ornamental as opposed to common purslane, the latter of which was richer in mineral content.⁶

Anti-inflammatory activity

In 2000, Chan et al. found that a 10% ethanolic extract of the dried leaves and stem of a P. oleracea cultivar displayed significant anti-inflammatory and analgesic properties after topical and intraperitoneal, but not oral, administration in comparison to diclofenac sodium, a synthetic drug used as active control. They added that these activities corresponded to the reputed effects of the traditional uses of the wild species.⁹

Wound healing activity

Rashed et al. reported in 2003 that a crude extract of P. oleracea accelerates wound healing. They used Mus musculus JVI-1 to show that fresh homogenized crude aerial parts of the plant topically applied on excision wound surfaces reduced wound surface areas and increased tensile strength. The best documented contraction was associated with a single dose of 50 mg, followed by two doses of 25 mg each.¹⁰

Oral lichen planus treatment

In 2010, Agha-Hosseini et al. conducted a randomized double-blind placebo-controlled 3-month study to assess the effectiveness of purslane in the treatment of oral lichen planus. Thirty-seven symptomatic patients (confirmed by biopsy) were divided into a purslane treatment group (n = 20) and a placebo group (n = 17). The investigators reported that partial to complete clinical improvement was observed in 83% of the treatment group, with no response in the remaining 17%, whereas partial improvement was seen in 17% of the placebo group, 73% had no response, and the condition was aggravated in 10% of the placebo group. No adverse side effects were reported in either group, and the researchers concluded that purslane was clinically effective in treating oral lichen planus and warrants consideration as a treatment option for the disorder.⁵

Other activities

In 2001, Radhakrishnan et al. identified several neuropharmacological actions, particularly anti-nociceptive and muscle-relaxing activity, with a range of effects on the central and peripheral nervous system observed in animal studies.¹ The betacyanins found in P. oleracea have subsequently been found to confer a protective effect against neurotoxicity, specifically, ameliorating the D-galactose-induced cognitive deficits in senescent mice.¹¹P. oleracea also has been shown to efficiently eliminate the endocrine-disrupting chemical bisphenol A from a hydroponic solution.¹²

In 2012, Yan et al. showed that three newly isolated homoisoflavonoids, known as portulacanones, and the compound 2,2’-dihydroxy-4’,6’-dimethoxychalcone selectively exhibited in vitro cytotoxic activities against four human cancer cell lines.²

Conclusions

This antioxidant-rich plant is found throughout the world and has long been associated with traditional health care. Modern research into its potential dermatologic uses is ongoing, but the evidence is relatively scarce. There are indications that the antioxidant, anti-inflammatory, and wound healing activity reportedly exhibited by purslane may be harnessed for various cutaneous applications. However, much more research is necessary to determine how extensive a role purslane may play in skin care.

References

1.J. Ethnopharmacol. 2001;76:171-6

2.Phytochemistry 2012;80:37-41

3.J. Biosci. Bioeng. 2007;103:420-6

4.J. Ethnopharmacol. 2000;73:445-51

5.Phytother. Res. 2010;24:240-4

6.Biomed. Res. Int. 2014;2014:296063

7.Int. J. Mol. Sci. 2012;13:10257-67

8.Nat Prod. Commun. 2014;9:45-50

9. J. Ethnopharmacol. 2000;73:445-51

10. J. Ethnopharmacol. 2003;88:131-6

11. Phytomedicine. 2010 Jun;17:527-32

12. Biosci. Biotechnol. Biochem. 2012;76:1015-7

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.

Portulaca oleracea, also known as purslane, has long been used in various traditional medicine systems to relieve pain and edema.¹Portulaca oleracea is a warm-climate annual plant originally found in the Middle East, North Africa, and the Indian subcontinent and now cultivated in the Arabian peninsula; Japan, where it is an abundant garden plant from spring to fall;^2,3 and throughout the world.

The use of P. oleracea, a member of the Portulacaceae family, as a vegetable as well as herbal medicine dates back several centuries.⁴ In modern times, purslane has been found to be rich in antioxidants, particularly omega-3 fatty acids, vitamins C and E, beta-carotene, melatonin, and glutathione, as well as several minerals.^5,6,7 Currently, it is considered one of the top ten most common plants in the world, and one of the most-used medical plants according to the World Health Organization.⁶ It is considered a weed in the United States, but is eaten in many parts of the world.

Antioxidant activity

Using two different assays, Uddin et al. determined in 2012 that P. oleracea cultivars exhibited significant antioxidant activity through various growth stages. In addition, the researchers suggested that purslane could provide multiple minerals as well as antioxidants in the context of nutraceutical products and functional food.⁷ Early this year, Silva et al. studied the antioxidant activity of P. oleracea leaves, flowers, and stems from two different locations in Portugal, with assays revealing significantly greater antioxidant activity in the stems of both samples compared to the leaves and flowers. However, the phenolic extracts of all three plant sections from both samples were found to protect DNA against hydroxyl radicals. The investigators concluded that their findings, particularly related to high antioxidant activity, support the potential benefits of purslane consumption to human health.⁸

A 2014 analysis of 13 collected purslane accessions revealed significant mineral content (particularly potassium, followed by nitrogen, sodium, calcium, magnesium, phosphorus, iron, zinc, and manganese) and showed that antioxidant activity was more strongly associated with ornamental as opposed to common purslane, the latter of which was richer in mineral content.⁶

Anti-inflammatory activity

In 2000, Chan et al. found that a 10% ethanolic extract of the dried leaves and stem of a P. oleracea cultivar displayed significant anti-inflammatory and analgesic properties after topical and intraperitoneal, but not oral, administration in comparison to diclofenac sodium, a synthetic drug used as active control. They added that these activities corresponded to the reputed effects of the traditional uses of the wild species.⁹

Wound healing activity

Rashed et al. reported in 2003 that a crude extract of P. oleracea accelerates wound healing. They used Mus musculus JVI-1 to show that fresh homogenized crude aerial parts of the plant topically applied on excision wound surfaces reduced wound surface areas and increased tensile strength. The best documented contraction was associated with a single dose of 50 mg, followed by two doses of 25 mg each.¹⁰

Oral lichen planus treatment

In 2010, Agha-Hosseini et al. conducted a randomized double-blind placebo-controlled 3-month study to assess the effectiveness of purslane in the treatment of oral lichen planus. Thirty-seven symptomatic patients (confirmed by biopsy) were divided into a purslane treatment group (n = 20) and a placebo group (n = 17). The investigators reported that partial to complete clinical improvement was observed in 83% of the treatment group, with no response in the remaining 17%, whereas partial improvement was seen in 17% of the placebo group, 73% had no response, and the condition was aggravated in 10% of the placebo group. No adverse side effects were reported in either group, and the researchers concluded that purslane was clinically effective in treating oral lichen planus and warrants consideration as a treatment option for the disorder.⁵

Other activities

In 2001, Radhakrishnan et al. identified several neuropharmacological actions, particularly anti-nociceptive and muscle-relaxing activity, with a range of effects on the central and peripheral nervous system observed in animal studies.¹ The betacyanins found in P. oleracea have subsequently been found to confer a protective effect against neurotoxicity, specifically, ameliorating the D-galactose-induced cognitive deficits in senescent mice.¹¹P. oleracea also has been shown to efficiently eliminate the endocrine-disrupting chemical bisphenol A from a hydroponic solution.¹²

In 2012, Yan et al. showed that three newly isolated homoisoflavonoids, known as portulacanones, and the compound 2,2’-dihydroxy-4’,6’-dimethoxychalcone selectively exhibited in vitro cytotoxic activities against four human cancer cell lines.²

Conclusions

This antioxidant-rich plant is found throughout the world and has long been associated with traditional health care. Modern research into its potential dermatologic uses is ongoing, but the evidence is relatively scarce. There are indications that the antioxidant, anti-inflammatory, and wound healing activity reportedly exhibited by purslane may be harnessed for various cutaneous applications. However, much more research is necessary to determine how extensive a role purslane may play in skin care.

References

1.J. Ethnopharmacol. 2001;76:171-6

2.Phytochemistry 2012;80:37-41

3.J. Biosci. Bioeng. 2007;103:420-6

4.J. Ethnopharmacol. 2000;73:445-51

5.Phytother. Res. 2010;24:240-4

6.Biomed. Res. Int. 2014;2014:296063

7.Int. J. Mol. Sci. 2012;13:10257-67

8.Nat Prod. Commun. 2014;9:45-50

9. J. Ethnopharmacol. 2000;73:445-51

10. J. Ethnopharmacol. 2003;88:131-6

11. Phytomedicine. 2010 Jun;17:527-32

12. Biosci. Biotechnol. Biochem. 2012;76:1015-7

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.

Portulaca oleracea, also known as purslane, has long been used in various traditional medicine systems to relieve pain and edema.¹Portulaca oleracea is a warm-climate annual plant originally found in the Middle East, North Africa, and the Indian subcontinent and now cultivated in the Arabian peninsula; Japan, where it is an abundant garden plant from spring to fall;^2,3 and throughout the world.

The use of P. oleracea, a member of the Portulacaceae family, as a vegetable as well as herbal medicine dates back several centuries.⁴ In modern times, purslane has been found to be rich in antioxidants, particularly omega-3 fatty acids, vitamins C and E, beta-carotene, melatonin, and glutathione, as well as several minerals.^5,6,7 Currently, it is considered one of the top ten most common plants in the world, and one of the most-used medical plants according to the World Health Organization.⁶ It is considered a weed in the United States, but is eaten in many parts of the world.

Antioxidant activity

Using two different assays, Uddin et al. determined in 2012 that P. oleracea cultivars exhibited significant antioxidant activity through various growth stages. In addition, the researchers suggested that purslane could provide multiple minerals as well as antioxidants in the context of nutraceutical products and functional food.⁷ Early this year, Silva et al. studied the antioxidant activity of P. oleracea leaves, flowers, and stems from two different locations in Portugal, with assays revealing significantly greater antioxidant activity in the stems of both samples compared to the leaves and flowers. However, the phenolic extracts of all three plant sections from both samples were found to protect DNA against hydroxyl radicals. The investigators concluded that their findings, particularly related to high antioxidant activity, support the potential benefits of purslane consumption to human health.⁸

A 2014 analysis of 13 collected purslane accessions revealed significant mineral content (particularly potassium, followed by nitrogen, sodium, calcium, magnesium, phosphorus, iron, zinc, and manganese) and showed that antioxidant activity was more strongly associated with ornamental as opposed to common purslane, the latter of which was richer in mineral content.⁶

Anti-inflammatory activity

In 2000, Chan et al. found that a 10% ethanolic extract of the dried leaves and stem of a P. oleracea cultivar displayed significant anti-inflammatory and analgesic properties after topical and intraperitoneal, but not oral, administration in comparison to diclofenac sodium, a synthetic drug used as active control. They added that these activities corresponded to the reputed effects of the traditional uses of the wild species.⁹

Wound healing activity

Rashed et al. reported in 2003 that a crude extract of P. oleracea accelerates wound healing. They used Mus musculus JVI-1 to show that fresh homogenized crude aerial parts of the plant topically applied on excision wound surfaces reduced wound surface areas and increased tensile strength. The best documented contraction was associated with a single dose of 50 mg, followed by two doses of 25 mg each.¹⁰

Oral lichen planus treatment

In 2010, Agha-Hosseini et al. conducted a randomized double-blind placebo-controlled 3-month study to assess the effectiveness of purslane in the treatment of oral lichen planus. Thirty-seven symptomatic patients (confirmed by biopsy) were divided into a purslane treatment group (n = 20) and a placebo group (n = 17). The investigators reported that partial to complete clinical improvement was observed in 83% of the treatment group, with no response in the remaining 17%, whereas partial improvement was seen in 17% of the placebo group, 73% had no response, and the condition was aggravated in 10% of the placebo group. No adverse side effects were reported in either group, and the researchers concluded that purslane was clinically effective in treating oral lichen planus and warrants consideration as a treatment option for the disorder.⁵

Other activities

In 2001, Radhakrishnan et al. identified several neuropharmacological actions, particularly anti-nociceptive and muscle-relaxing activity, with a range of effects on the central and peripheral nervous system observed in animal studies.¹ The betacyanins found in P. oleracea have subsequently been found to confer a protective effect against neurotoxicity, specifically, ameliorating the D-galactose-induced cognitive deficits in senescent mice.¹¹P. oleracea also has been shown to efficiently eliminate the endocrine-disrupting chemical bisphenol A from a hydroponic solution.¹²

In 2012, Yan et al. showed that three newly isolated homoisoflavonoids, known as portulacanones, and the compound 2,2’-dihydroxy-4’,6’-dimethoxychalcone selectively exhibited in vitro cytotoxic activities against four human cancer cell lines.²

Conclusions

This antioxidant-rich plant is found throughout the world and has long been associated with traditional health care. Modern research into its potential dermatologic uses is ongoing, but the evidence is relatively scarce. There are indications that the antioxidant, anti-inflammatory, and wound healing activity reportedly exhibited by purslane may be harnessed for various cutaneous applications. However, much more research is necessary to determine how extensive a role purslane may play in skin care.

References

1.J. Ethnopharmacol. 2001;76:171-6

2.Phytochemistry 2012;80:37-41

3.J. Biosci. Bioeng. 2007;103:420-6

4.J. Ethnopharmacol. 2000;73:445-51

5.Phytother. Res. 2010;24:240-4

6.Biomed. Res. Int. 2014;2014:296063

7.Int. J. Mol. Sci. 2012;13:10257-67

8.Nat Prod. Commun. 2014;9:45-50

9. J. Ethnopharmacol. 2000;73:445-51

10. J. Ethnopharmacol. 2003;88:131-6

11. Phytomedicine. 2010 Jun;17:527-32

12. Biosci. Biotechnol. Biochem. 2012;76:1015-7

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.

As summertime approaches, opportunities for outdoor activities increase. For many of our patients, summer inspires a desire to have aesthetic procedures in preparation for outdoor events, such as weddings and vacations. We must, however, be mindful that increased sun exposure after some aesthetic procedures can mean an increased risk of complications.

The main complication we worry about with sun exposure is, of course, hyperpigmentation. The risk is low with injectable procedures such as botulinum toxin and fillers, but sun protection is still encouraged, especially in skin types III-VI. The risk increases greatly with chemical peels and laser and light-based procedures, such as intense pulsed light, vascular lasers, pigment lasers, laser hair removal, and especially nonablative and ablative resurfacing (including nonlaser resurfacing such as dermabrasion).

Sun protection should be encouraged, even with seemingly less invasive procedures, such as electrodessication. I once had a patient with type-IV skin tell me at her first visit that, years before, she had electrodessication on her face for DPN (dermatosis papulosa nigra), a procedure she had done on several occasions without complications and great results. However, she went to a party on a boat the weekend after the procedure and developed hyperpigmentation at the procedure areas, and she still had a few dark macules several years later.

At a follow-up visit, she said the doctor told her she should not have gone out on the boat and should have worn sunscreen. Of course, she was highly upset that she wasn’t advised about sun protection at the time of the procedure. This is one of several stories I’ve heard or seen of complications and postinflammatory hyperpigmentation after an aesthetic procedure, when the patients felt that the treating physician or practitioner did not counsel them about sun exposure during the consultation or treatment visit. It seems intuitive, but I’ve made it a habit to make sun protection part of my counseling routine.

In my practice, we often give patients sunscreen to apply immediately after a procedure. Specifically encouraging the use of zinc- and/or titanium-based, broad-spectrum, noncomedogenic physical blockers that are SPF 30 or higher may help reduce the risk of potential irritation or allergy and subsequent postinflammatory pigmentary alteration from chemical blocking ingredients. We provide a postprocedure handout, and the medical assistant also will counsel about sun protection when applying it to the patient or reviewing postprocedure instructions. So the patient is counseled at least three times: By me during consultation or pre-procedure, by the medical assistant post procedure, and by written instructions.

Vigorous sun protection is encouraged for at least 1 week after any aesthetic procedure (and longer if the downtime is longer or if multiple treatments are required). Some practices also use antioxidant serums to reduce free radicals, encourage healing, and reduce the risk of hyperpigmentation after procedures. Wide-brimmed hats also are encouraged, particularly after resurfacing or photodynamic therapy (PDT). We give patients sun-protective hats when they leave our office after PDT. We counsel them to practice vigorous sun protection for at least 1 week and to avoid sitting by a window for 48 hours after the procedure so as to not reactivate the levulan.

Delaying more high-risk procedures, such as laser treatments, until after the summer months may be appropriate if sun cannot be avoided to mitigate the risk of complications. If a patient comes to the office for a laser procedure and is visibly more tan than at the time of the last treatment, I will counsel about risks, adjust the settings appropriately, or even delay the treatment altogether to a time when the tan has faded. This is particularly important for lasers and light treatments for which melanin is the target chromosphere, such as intense pulsed light and laser hair removal. Although UV exposure is more intense in the summer, in our practice in Southern California we follow these principles year-round for the safety of our patients.

Dr. Wesley and Dr. Talakoub are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

As summertime approaches, opportunities for outdoor activities increase. For many of our patients, summer inspires a desire to have aesthetic procedures in preparation for outdoor events, such as weddings and vacations. We must, however, be mindful that increased sun exposure after some aesthetic procedures can mean an increased risk of complications.

The main complication we worry about with sun exposure is, of course, hyperpigmentation. The risk is low with injectable procedures such as botulinum toxin and fillers, but sun protection is still encouraged, especially in skin types III-VI. The risk increases greatly with chemical peels and laser and light-based procedures, such as intense pulsed light, vascular lasers, pigment lasers, laser hair removal, and especially nonablative and ablative resurfacing (including nonlaser resurfacing such as dermabrasion).

Sun protection should be encouraged, even with seemingly less invasive procedures, such as electrodessication. I once had a patient with type-IV skin tell me at her first visit that, years before, she had electrodessication on her face for DPN (dermatosis papulosa nigra), a procedure she had done on several occasions without complications and great results. However, she went to a party on a boat the weekend after the procedure and developed hyperpigmentation at the procedure areas, and she still had a few dark macules several years later.

At a follow-up visit, she said the doctor told her she should not have gone out on the boat and should have worn sunscreen. Of course, she was highly upset that she wasn’t advised about sun protection at the time of the procedure. This is one of several stories I’ve heard or seen of complications and postinflammatory hyperpigmentation after an aesthetic procedure, when the patients felt that the treating physician or practitioner did not counsel them about sun exposure during the consultation or treatment visit. It seems intuitive, but I’ve made it a habit to make sun protection part of my counseling routine.

In my practice, we often give patients sunscreen to apply immediately after a procedure. Specifically encouraging the use of zinc- and/or titanium-based, broad-spectrum, noncomedogenic physical blockers that are SPF 30 or higher may help reduce the risk of potential irritation or allergy and subsequent postinflammatory pigmentary alteration from chemical blocking ingredients. We provide a postprocedure handout, and the medical assistant also will counsel about sun protection when applying it to the patient or reviewing postprocedure instructions. So the patient is counseled at least three times: By me during consultation or pre-procedure, by the medical assistant post procedure, and by written instructions.

Vigorous sun protection is encouraged for at least 1 week after any aesthetic procedure (and longer if the downtime is longer or if multiple treatments are required). Some practices also use antioxidant serums to reduce free radicals, encourage healing, and reduce the risk of hyperpigmentation after procedures. Wide-brimmed hats also are encouraged, particularly after resurfacing or photodynamic therapy (PDT). We give patients sun-protective hats when they leave our office after PDT. We counsel them to practice vigorous sun protection for at least 1 week and to avoid sitting by a window for 48 hours after the procedure so as to not reactivate the levulan.

Delaying more high-risk procedures, such as laser treatments, until after the summer months may be appropriate if sun cannot be avoided to mitigate the risk of complications. If a patient comes to the office for a laser procedure and is visibly more tan than at the time of the last treatment, I will counsel about risks, adjust the settings appropriately, or even delay the treatment altogether to a time when the tan has faded. This is particularly important for lasers and light treatments for which melanin is the target chromosphere, such as intense pulsed light and laser hair removal. Although UV exposure is more intense in the summer, in our practice in Southern California we follow these principles year-round for the safety of our patients.

Dr. Wesley and Dr. Talakoub are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

As summertime approaches, opportunities for outdoor activities increase. For many of our patients, summer inspires a desire to have aesthetic procedures in preparation for outdoor events, such as weddings and vacations. We must, however, be mindful that increased sun exposure after some aesthetic procedures can mean an increased risk of complications.

The main complication we worry about with sun exposure is, of course, hyperpigmentation. The risk is low with injectable procedures such as botulinum toxin and fillers, but sun protection is still encouraged, especially in skin types III-VI. The risk increases greatly with chemical peels and laser and light-based procedures, such as intense pulsed light, vascular lasers, pigment lasers, laser hair removal, and especially nonablative and ablative resurfacing (including nonlaser resurfacing such as dermabrasion).

Sun protection should be encouraged, even with seemingly less invasive procedures, such as electrodessication. I once had a patient with type-IV skin tell me at her first visit that, years before, she had electrodessication on her face for DPN (dermatosis papulosa nigra), a procedure she had done on several occasions without complications and great results. However, she went to a party on a boat the weekend after the procedure and developed hyperpigmentation at the procedure areas, and she still had a few dark macules several years later.

At a follow-up visit, she said the doctor told her she should not have gone out on the boat and should have worn sunscreen. Of course, she was highly upset that she wasn’t advised about sun protection at the time of the procedure. This is one of several stories I’ve heard or seen of complications and postinflammatory hyperpigmentation after an aesthetic procedure, when the patients felt that the treating physician or practitioner did not counsel them about sun exposure during the consultation or treatment visit. It seems intuitive, but I’ve made it a habit to make sun protection part of my counseling routine.

In my practice, we often give patients sunscreen to apply immediately after a procedure. Specifically encouraging the use of zinc- and/or titanium-based, broad-spectrum, noncomedogenic physical blockers that are SPF 30 or higher may help reduce the risk of potential irritation or allergy and subsequent postinflammatory pigmentary alteration from chemical blocking ingredients. We provide a postprocedure handout, and the medical assistant also will counsel about sun protection when applying it to the patient or reviewing postprocedure instructions. So the patient is counseled at least three times: By me during consultation or pre-procedure, by the medical assistant post procedure, and by written instructions.

Vigorous sun protection is encouraged for at least 1 week after any aesthetic procedure (and longer if the downtime is longer or if multiple treatments are required). Some practices also use antioxidant serums to reduce free radicals, encourage healing, and reduce the risk of hyperpigmentation after procedures. Wide-brimmed hats also are encouraged, particularly after resurfacing or photodynamic therapy (PDT). We give patients sun-protective hats when they leave our office after PDT. We counsel them to practice vigorous sun protection for at least 1 week and to avoid sitting by a window for 48 hours after the procedure so as to not reactivate the levulan.

Delaying more high-risk procedures, such as laser treatments, until after the summer months may be appropriate if sun cannot be avoided to mitigate the risk of complications. If a patient comes to the office for a laser procedure and is visibly more tan than at the time of the last treatment, I will counsel about risks, adjust the settings appropriately, or even delay the treatment altogether to a time when the tan has faded. This is particularly important for lasers and light treatments for which melanin is the target chromosphere, such as intense pulsed light and laser hair removal. Although UV exposure is more intense in the summer, in our practice in Southern California we follow these principles year-round for the safety of our patients.

Dr. Wesley and Dr. Talakoub are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.