J Keckstein

Klinički centar Srbije, Beograd, Central Serbia, Serbia

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Publications (76)77.09 Total impact

  • [show abstract] [hide abstract]
    ABSTRACT: OBJECTIVE: The aim of the study was to evaluate whether the presence of utero-rectal adhesions demonstrated by transvaginal sonography (TVS) could aid as a simple sonographic predictor for deep infiltrating endometriosis of the rectum in patients with symptoms suggestive of endometriosis. METHODS: A prospective study was conducted in pelvic pain clinics including one-hundred and forty-two symptomatic women scheduled for laparoscopy due to symptoms suggestive of endometriosis. Patients were prospectively assessed via TVS prior to laparoscopy and radical resection of disease and histological confirmation was performed. Sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV), accuracy and positive and negative likelihood ratios (LR+ and LR-) were calculated. RESULTS: In total, 34 (29%) of patients exhibited deep infiltrating endometriosis (DIE) of the bowel. Sensitivity, specificity, PPV, NPV, accuracy, LR+ and LR- for a negative sliding sign as shown by TVS regarding the presence of DIE of the rectum was 85%, 96%, 91%, 94%, 93.1%, 23.6 and 0.15. CONCLUSIONS: Sonographic demonstration of utero-rectal adhesions reflected by a positive uterine sliding sign is an easy at hand method for prediction of the presence of DIE involving the rectum. This could be a valuable "red flag sign" for triaging patients for tertiary referral centres and specialized clinics for detailed investigation.
    Ultrasound in Obstetrics and Gynecology 02/2013; · 3.56 Impact Factor
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    ABSTRACT: The idea of quality improvement in the management of endometriosis has been brought to attention throughout Europe. This - first and foremost - includes the implementation of centers specialized in treating endometriosis. This leads to qualification of both physicians and other medical staff, enforcement of research efforts, and informing the patients, the public, politicians, healthcare providers, and industry. Given limited budgets, focusing on the existing national commitment may be the first step.
    Gynecologic and Obstetric Investigation 02/2013; · 1.10 Impact Factor
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    ABSTRACT: The aim of this study was to compare the diagnostic performance of clinical vaginal examination with that of transvaginal sonography (TVS) in the presurgical diagnosis of deep infiltrating endometriosis. One-hundred and fifty-five women with symptoms suggestive of endometriosis were included. One-hundred and twenty-nine patients met the inclusion criteria and were prospectively and independently assessed by vaginal examination and TVS prior to a diagnostic laparoscopy and, where appropriate, radical resection and histological confirmation of endometriosis was performed. Sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV) and positive and negative likelihood ratios (LR+ and LR-) were calculated for each test method. In total, 83 (64%) women had histological confirmation of endometriosis, 52 (40%) of whom had deep infiltrating endometriosis. The prevalence of endometriosis on the uterosacral ligaments, pouch of Douglas, vagina, bladder, rectovaginal space and rectosigmoid was 23.3%, 16.3%, 8.5%, 3.1%, 6.9% and 24%. PPV, NPV, LR+ and LR- for vaginal examination were 92%, 87%, 41.56 and 0.60 for ovarian endometriosis; 43%, 84%, 2.48 and 0.63 for uterosacral ligament disease; 64%, 95%, 9.14 and 0.26 for involvement of the pouch of Douglas; 80%, 97%, 42.91 and 0.28 for vaginal endometriosis; 78%, 98%, 46.67 and 0.23 for endometriosis of the rectovaginal space; 100%, 98%, 75.60 and 0.75 for bladder involvement; 86%, 84%, 18.97 and 0.63 for rectosigmoidal endometriosis. Values for TVS were similar with regard to vaginal and rectovaginal space endometriosis, but were clearly superior to vaginal examination in cases of ovarian (87%, 99%, 24.56 and 0.04), uterosacral ligament (91%, 90%, 31.35 and 0.37) and rectosigmoidal (97%, 97%, 88.51 and 0.1) endometriosis. TVS is a more useful test than is vaginal examination in detecting endometriosis in the ovaries and rectosigmoid.
    Ultrasound in Obstetrics and Gynecology 04/2011; 37(4):480-7. · 3.56 Impact Factor
  • Source
    Radmila Sparić, Gernot Hudelist, Joerg Keckstein
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    ABSTRACT: Deep infiltrating endometriosis is a form of endometriosis penetrating deeply under the peritoneal surface causing pain and infertility. Assessment of the pelvis by laparoscopy and histological confirmation of the disease is considered the golden standard of diagnosis. We are presenting a patient diagnosed with deep infiltrating endometriosis by transvaginal ultrasound and treated with minimally invasive radical surgery including segmental resection of the bowel. Transvaginal sonography has an important role in detecting deep endometriosis of the pelvis. Fertility sparing surgery is the treatment of choice in symptomatic women wishing to retain fertility, since drugs used for endometriosis interfere with ovulation.The success of the surgery depends on the accuracy of the preoperative diagnosis. A multidisciplinary approach in managing deep endometriosis is mandatory in order to offer patients the best possible treatment using the combined skills of the colorectal and gynaecologic surgical teams. The presented case exhibits the feasibility of laparoscopic approach to severe pelvic endometriosis with bowel involvement.
    Srpski arhiv za celokupno lekarstvo 01/2011; 139(7-8):531-5. · 0.23 Impact Factor
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    ABSTRACT: To critically analyze the diagnostic value of transvaginal sonography (TVS) for non-invasive, presurgical detection of bowel endometriosis. MEDLINE (1966-2010) and EMBASE (1980-2010) databases were searched for relevant studies investigating the diagnostic accuracy of TVS for diagnosing deep infiltrating endometriosis involving the bowel. Diagnosis was established by laparoscopy and/or histopathological analysis. Likelihood ratios (LRs) were recalculated in addition to traditional measures of effectiveness. Out of 188 papers, a total of 10 studies fulfilled predefined inclusion criteria involving 1106 patients with suspected endometriosis. The prevalence of bowel endometriosis varied from 24 to 73.3%. LR+ ranged from 4.8 to 48.56 and LR- ranged from 0.02 to 0.36, with wide confidence intervals. Pooled estimates of sensitivities and specificities were 91 and 98%; LR+ and LR- were 30.36 and 0.09; and positive and negative predictive values were 98 and 95%, respectively. Three of the studies used bowel preparations to enhance the visibility of the rectal wall; one study directly compared the use of water contrast vs. no prior bowel enema, for which the LR- was 0.04 and 0.47, respectively. TVS with or without the use of prior bowel preparation is an accurate test for non-invasive, presurgical detection of deep infiltrating endometriosis of the rectosigmoid.
    Ultrasound in Obstetrics and Gynecology 10/2010; 37(3):257-63. · 3.56 Impact Factor
  • Geburtshilfe Und Frauenheilkunde - GEBURTSH FRAUENHEILK. 01/2010; 70(05).
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    ABSTRACT: Complications associated with initial abdominal entry are a prime concern for laparoscopic surgeons. In order to minimize first access-related complications in laparoscopy, several techniques and technologies have been introduced in the past years. This investigation compares two laparoscopic access techniques. 194 women underwent laparoscopic surgery for simple ovarian cysts: 93 were assigned to direct optical access (DOA) abdominal entry (group I), and 101 women to classical closed method by Verres needle, pneumoperitoneum and trocar entry (group II). The following parameters were compared: time required for entry into abdomen, occurrence of vascular and/or bowel injury, blood loss. The results were analyzed using SAS software. p-value<0.05 was considered as significant. No statistically significant differences were observed in the occurrence of blood loss and minor vascular injury between the two techniques, as well as minor bowel injuries; time for of abdominal entry, instead, were significantly reduced in the DOA group. The results of the preliminary comparison between the DOA and the Verres methods, commonly used by gynecologists, suggests that the visual entry system confers a statistical advantage over closed entry technique with Verres needle, in terms of time saving and due to the minor vascular and bowel injuries, thus enabling a safe and expeditious, visually-guided, entry for surgeons.
    European journal of obstetrics, gynecology, and reproductive biology 11/2009; 148(2):191-4. · 1.97 Impact Factor
  • G Hudelist, J Keckstein
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    ABSTRACT: Endometriosis is one the most challenging gynaecological disorders affecting 10-15% of women in their reproductive years. Considerable diagnostic delay of up to 8 years from presenting symptoms often confers a heavy economic and social price. Over the past years, additional diagnostic tools such as transvaginal scanning (TVS) and/or MRI have been recommended as an appropriate investigation to diagnose ovarian endometriomas or adenomyosis. Several lines of recent evidence strongly suggests that the use of TVS also has an important role in detecting DIE of the pelvis not only involving the ovaries but also structures such as the vagina, the rectovaginal space, the uterosacral ligaments, the bladder or the rectal wall.
    Praxis 06/2009; 98(11):603-7.
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    ABSTRACT: Estrogen loss at menopause has a profound influence on skin, with postmenopausal atrophy and loss of tone and elasticity. Because more than 50% of major laparoscopic complications occur during initial entry under the abdominal skin, the efficacy and the safety of two laparoscopic access techniques were compared in postmenopausal women. One hundred eighty-six postmenopausal women underwent laparoscopic surgery for simple ovarian cysts: 89 were assigned to direct optical access (DOA), abdominal entry (group I), and 97 to the classic closed Veress needle approach, pneumoperitoneum, and trocar entry (group II). The following parameters were compared: time needed for entry into the abdomen, occurrence of vascular and/or bowel injury, and blood loss. Results were analyzed using SAS software, considering P value less than 0.05 as significant. No statistically significant differences were observed in the occurrence of major vascular and/or bowel injury between the two techniques (P > 0.05), whereas time for abdominal entry was significantly reduced in the DOA group, as well as the occurrence of minor vascular injuries (P < 0.05). Results of this preliminary comparison on the DOA and the Veress methods, commonly used by gynecologists, suggest that the visual entry system offers a statistical advantage over the closed Veress needle approach, in terms of time saving and limiting minor vascular injuries, thus enabling a safe and fast visually guided entry in postmenopausal women.
    Menopause (New York, N.Y.) 05/2009; 16(5):966-70. · 3.08 Impact Factor
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    ABSTRACT: More than 50% of major laparoscopic complications occur during the initial entry into the abdomen. We investigated the efficacy and the safety of two laparoscopic access techniques: the direct optical access (DOA) versus the classical open entry, as described by Hasson. Two hundred and two premenopausal women, homogeneous in age, parity, and body mass index undergoing laparoscopic surgery for simple ovarian cysts, were prospectively, randomly assigned to either open or DOA abdominal entry for laparoscopic surgery. The following parameters were compared: duration of access for entry into the abdomen, occurrence of vascular and/or bowel injury, and blood loss. The results were analyzed by using SAS software (SAS Institute, Inc., Cary, NC), considering a P-value of <0.05 as significant. No statistically significant differences were observed in the occurrence of major vascular and/or bowel injury between the two techniques. However, time for establishment of abdominal entry was significantly reduced in the DOA group, as was the blood loss (P < 0.05). The results of this preliminary comparison on the DOA and the Hasson methods, commonly used by general surgeons and less frequently by gynecologists, suggest that the visual entry system confers a little statistical advantage over the traditional Hasson entry, in terms of safety, minimal time saving, and in reducing blood loss, allowing a safe, fast, visually guided entry.
    Journal of Laparoendoscopic & Advanced Surgical Techniques 04/2009; 19(4):529-33. · 1.07 Impact Factor
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    ABSTRACT: Patients with deep infiltrating endometriosis (DIE) of the rectum often benefit from surgical treatment, including disc or segmental bowel resection, in terms of pain relief and treatment of infertility. The aim of the present study was to evaluate the diagnostic accuracy of transvaginal sonography (TVS) for preoperative detection of rectal DIE. Furthermore, we aimed to investigate whether TVS can predict infiltration depth based on the distortion of characteristic sonomorphologic features of the rectal wall. Two-hundred patients with symptoms of endometriosis were prospectively assessed by TVS for the presence of rectal DIE before undergoing laparoscopic radical resection of endometriosis including segmental resection of the bowel in affected cases. Sensitivities, specificities, positive and negative predictive values (PPV and NPV), positive and negative likelihood ratios (LHR) and test accuracies were then calculated for the presence of infiltration of the serosal/smooth muscle (S/M) layer and submucosal/mucosal (MUC) layer as demonstrated by TVS and confirmed by histopathological analysis. Rectal endometriosis was confirmed in 43 out of 195 (22%) cases. The sensitivity, specificity, PPV, NPV, test accuracy and positive and negative LHR of TVS on S/M infiltration were 98%, 99%, 98%, 99%, 99%,150.24 and 0.02, respectively, whereas respective data on MUC involvement were 62%, 96%, 53%, 97%, 93.8%, 16 and 0.4. TVS is a highly valuable tool in detecting rectal endometriosis preoperatively. Within this, S/M endometriotic infiltration can be accurately predicted, whereas TVS is less valuable for detection of MUC involvement.
    Human Reproduction 03/2009; 24(5):1012-7. · 4.67 Impact Factor
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    ABSTRACT: The aim of the present study was to evaluate the accuracy of routine clinical examination (per vaginam, PV) combined with transvaginal sonography (TVS) for presurgical, non-invasive diagnosis of endometriosis. Two-hundred women with symptoms suggestive of endometriosis were prospectively assessed by PV and TVS prior to laparoscopy and radical resection of disease and histological confirmation. Prevalence of endometriosis on the right/left (r/l) ovary, r/l uterosacral ligament (USL), pouch of Douglas (POD), vagina, bladder, rectovaginal space (RVS) and rectum was 12%, 13%, 12%, 22%, 15%, 11%, 2%, 4% and 24%. Sensitivities, specificities, positive and negative predictive values and positive and negative likelihood ratios for combined use of TVS and PV resulted in 96/100%, 100/99%, 100/93%, 93/100% and -;0.04/87.0;- for the r/l ovarian endometriosis; 67/84%, 97/86%, 73/62%, 96/95% and 19.56;0.35/5.97;0.19 for the r/l USL disease; 87%, 98%, 90%, 98% and 49.11;0.14 for involvement of the POD; 82%, 99%, 95%, 98% and 145.64;0.18 for vaginal endometriosis; 88%, 99%, 78%, 99% and 84.0;0.13 for endometriosis of the RVS; 75%, 98%, 50%, 99% and 49.0;0.25 for bladder involvement and 96%, 98%, 94%, 99% and 48.56;0.04 for rectal endometriosis. The combination of PV and TVS accurately predicts the presence of endometriosis affecting the ovaries, vagina, rectum, USL, RVS and POD in patients with suspected endometriosis. We suggest the routine combination of PV and TVS as an essential part of the standard primary assessment of pelvic pain patients with suspected endometriosis.
    Human Reproduction 03/2009; 24(5):1018-24. · 4.67 Impact Factor
  • G. Hudelist, J. Keckstein
    Schweizerische Rundschau Fur Medizin Praxis - SCHWEIZ RUNDSCH MED PRAX. 01/2009; 098(11):603-607.
  • K Leeb, J Gärtner, W Pflanzl, J Keckstein
    Geburtshilfe Und Frauenheilkunde - GEBURTSH FRAUENHEILK. 01/2009; 69(05).
  • Geburtshilfe Und Frauenheilkunde - GEBURTSH FRAUENHEILK. 01/2009; 69(05).
  • E Janschek, G Rauter, G Pollak, J Keckstein
    Geburtshilfe Und Frauenheilkunde - GEBURTSH FRAUENHEILK. 01/2009; 69(05).
  • Geburtshilfe Und Frauenheilkunde - GEBURTSH FRAUENHEILK. 01/2009; 69(05).
  • Gernot Hudelist, Joerg Keckstein, Jeremy T Wright
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    ABSTRACT: This article discusses the history surrounding the debate on the etiopathology of endometriosis, specifically deep infiltrating endometriosis, and traces the controversies in its management that are as pertinent today as they were when the disease was first described in the late 19th and early 20th centuries.
    Fertility and sterility 11/2008; 92(5):1536-43. · 3.97 Impact Factor
  • Geburtshilfe Und Frauenheilkunde - GEBURTSH FRAUENHEILK. 01/2008; 68(04).
  • J. Keckstein, J. Hucke, U. Ulrich
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    ABSTRACT: Die operative Therapie der Endometriose ist als die wichtigste therapeutische Maßnahme anzusehen. Die Hauptindikation für eine Operation ist der starke Schmerz, die Sterilität sowie eine progressive Veränderung der Organanatomie. Ziel ist es, die Endometriose zu inaktivieren bzw. zu beseitigen. Der Widerspruch zwischen einer vollständigen Entfernung der Endometriose und dem Wunsch nach Organerhalt erfordert individuelle Lösungen. Die Auswahl der Operation erfolgt in Abhängigkeit des Alters, der Vorgeschichte, der anatomischen Situation und des Wunsches der Patientin. Die Entscheidung operative Laparotomie oder endoskopischer Eingriff wird durch den Befund und die Erfahrung des Operateurs bestimmt. Die Adenomyosis uteri wird meist durch eine Hysterektomie therapiert, wobei auch hier konservative Operationsverfahren zur Anwendung kommen. Die Ergebnisse der operativen Therapie zeigen bei entsprechender Indikationswahl und individueller Operationsplanung eine hohe Erfolgsrate. Endoskopische Operationen scheinen der konventionellen Laparotomie überlegen zu sein. Surgery is the most important approach to endometriosis. The main indications for surgery are severe pain, sterility and progressive changes to the anatomical structures of pelvic organs. The aim is to inactivate and/or remove the endometriotic lesions. There is a tension between complete removal of all endometriotic tissue and the desire to preserve the organs, which means that individually tailored treatment strategies are necessary. The surgical procedure selected depends on the patient’s age and previous medical history, the anatomical situation and the patient’s wishes. The surgeon’s experience is the decisive factor in the decision on whether a laparotomy or laparoscopic surgery is done. Adenomyosis is genereally treated by hysterectomy in most cases; conservative surgical procedures can be successful in selected cases. The success rates after surgical treatment of endometriosis are high, providing that patients are carefully selected and the surgery is individually planned. On the whole, endoscopic surgery seems to be superior to conventional laparotomy.
    Der Gynäkologe 01/2008; 40(7):536-546.

Publication Stats

388 Citations
77.09 Total Impact Points

Institutions

  • 2011
    • Klinički centar Srbije
      • Institute of Gynecology and Obstetrics
      Beograd, Central Serbia, Serbia
    • University of Surrey
      Guilford, England, United Kingdom
  • 2002–2005
    • Landeskrankenhaus Villach
      Villach, Carinthia, Austria
  • 2000
    • University of Bonn - Medical Center
      Bonn, North Rhine-Westphalia, Germany
  • 1986–2000
    • Universität Ulm
      • Clinic of Gynecology and Obstetrics
      Ulm, Baden-Württemberg, Germany
  • 1994–1996
    • Clinic for Minimally Invasive Surgery
      Berlín, Berlin, Germany
  • 1992–1995
    • Universitäts- und Rehabilitationskliniken Ulm
      Ulm, Baden-Württemberg, Germany