Complications des lymphadénectomies cœlioscopiques en oncologie gynécologique : 1102 interventions chez 915 patientes

OBJECTIVE

Evaluate complications of pelvic and para aortic laparoscopic lymphadenectomies in oncologic gynaecology to confirm the surgical approach and include it in current therapy.

PATIENTS AND METHODS

From December 1998 to March 2004, 915 patients underwent pelvic and/or aortic lymphadenectomies by laparoscopy. Among them, 771 were operated on at the centre Oscar-Lambret (Lille, France), whereas 144 underwent surgery at the institut Claudius-Regaud (Toulouse, France). Laparoscopic lymphadenectomies could be indicated along with other procedures in 98 early adnexal carcinomas, in 237 cervical carcinomas and 216 locally advanced cervical carcinomas. It may also be included as part of cancer therapy with (radical) hysterectomy/trachelectomy in 161 endometrial and 203 up front surgical cervical carcinomas.

RESULTS

A total of 1102 pelvic and aortic lymphadenectomies have been performed: 714 pelvic (694 trans peritoneal, 20 extra peritoneal) and 388 aortic lymphadenectomies (154 transperitoneal, 234 extraperitoneal). Seventeen open surgeries (1.85%) were necessary for technical reasons or complications.

DISCUSSION AND CONCLUSIONS

Laparoscopic lymphadenectomies are safe and accurate with no more complications than by laparotomy and no death up to now.

M3-like muscarinic receptors mediate Ca2+ influx in rat mesencephalic GABAergic neurones through a protein kinase C-dependent mechanism

GABAergic neurones in the mesencephalon are important regulators of dopamine neurones. Cholinergic projections from mesopontine nuclei preferentially synapse onto these GABAergic neurones, thus suggesting that ACh can regulate dopamine neurones indirectly by modulating GABAergic interneurones. Muscarinic receptors mediate excitation of these interneurones through a Ca(2+)-dependent mechanism. Using a mesencephalic primary culture model, we show here that muscarine (10 microM) increases intracellular Ca2+ concentrations ([Ca2+]i) in GABAergic interneurones. Compatible with previous anatomical data, our pharmacological studies further suggest that the M3 receptor is the primary mediator of this increase. The rise in [Ca2+]i induced by muscarine was not activity-dependent but required influx of Ca2+ from the extracellular medium. Consistent with the known coupling of the M3 receptor to PKC, the effect of muscarine was blocked by bisindolylmaleimide, a selective PKC antagonist. The effect of muscarine was inhibited by SKF 96365 and verapamil, drugs known to block non-selective cationic channels such as those formed by transient receptor potential (TRPC) proteins. Finally, GABAergic neurones were found to be immunopositive for TRPC1, 3, 5 and 6. Taken together, these results suggest that the Ca(2+)-dependent regulation of mesencephalic GABAergic neurones by muscarinic receptors requires activation of some receptor-operated Ca2+ channels through a PKC-dependent mechanism.

Prise en charge des sarcomes des tissus mous en première rechute locale isolée : étude rétrospective de 83 cas

PURPOSE

To analyse the management and clinical outcome of patients treated for a first isolated local recurrence of soft tissue sarcoma (trunk or extremities) and to identify prognosis factors.

PATIENTS AND MATERIAL

This is a retrospective study of 83 adult patients treated between 1980 and 1999. Mean tumor size was 6 cm. Most sarcomas were located in extremities (N =74), were deep (N =60), and proximal (N =53). Thirty involved nerves or vessels. Histologic subtypes were mainly grade 2 (42%) or 3 (36%) histocytofibrosarcomas (49%) and liposarcomas (20%). Surgical treatment of recurrences consisted in wide excision (32 cases), marginal resection (46 cases), five patients requiring amputation. Final results were R0 (N =33), R1 (N =47) or R2 (N =3) resection. Beside surgery, six patients received neoadjuvant and seven others adjuvant chemotherapy. Twenty-three patients received postoperative external beam radiotherapy (EBRT) (mean dose 55 Gy) and 26 interstitial (192)Ir low dose rate brachytherapy (BCT) (mean dose 45 Gy for BCT alone, 22 Gy when associated with EBRT), 19 patients being re-irradiated.

RESULTS

Mean follow up was 59 months. Thirty-seven (45%) tumors relapsed, 62% locally as first event. Nineteen patients developed secondary distant metastases. Multivariate analysis showed only tumour depth (P =0.05) and re-resection for primary R1 resection for the recurrence (P =0.018) being independent prognosis factors for tumour control, radiotherapy (EBRT and/or BCT) being significant in univariate analysis (P =0.05). Overall survival rate was 73, 54, and 47% at respectively 3, 5 and 10 years, and was 65, 35 and 32% after a further local recurrence. Multivariate analysis showed trunk (P =0.0001) or inferior extremity locations (P =0.023), symptomatic (P =0.001), high grade (P =0.01), deep (P = 0.01) tumours, and the occurrence of a further local failure (P =0.004) as unfavourable characteristics for overall survival.

CONCLUSION

Because of the high relapse rate in this series, a first isolated local recurrence of STS increases mainly the risk of a subsequent local relapse. Quality of local treatment for the first local relapse is decisive. When a conservative treatment is feasible, it should combine surgical resection and radiotherapy, brachytherapy being the best suited in previously irradiated patients. Efforts have to be pursued to increase quality of the treatment of primary tumours, at best performed in centers that have expertise in this field.

[Fecal incontinence following anal sphincter rupture: influence of the aetiology on the repair results]

Short-term functional results are usually good after sphincter repair but they could deteriorate with time if the disruption is due to obstetric damage. The aim of this study was to compare short and long-term results after sphincter repair according to the etiology of the damage.

METHODS

Fifty-five women have been operated on for a sphincter disruption due to obstetrical damage (Ob) (28) or to postoperative damage (Op) (27) and were retrospectively studied. Surgical procedure was similar for every patients but the puborectalis muscle was also approximated in case of obstetric damage. Functional results were recorded by clinical examinations two months after the operation and during the year 2001.

RESULTS

The two groups were similar, except for the rate of defunctionning stoma undergone and for the duration of symptoms before the operation. Mortality and morbidity were similar between the two groups. Short-term functional results were better in the postoperative group (96 vs 78%) (P =0.05). At the end of the follow-up the results remained significantly better in group Op (85 vs 65%; P <0.05). The cumulative rates of functional good results also decreased more rapidly in group Ob but the difference was not significant.

CONCLUSION

Short and long-time functional results after sphincter repair seem to be better in case of postoperative disruption. Pudendal nerve damages frequently observed after traumatic delivery could explain this difference.

[Lymph node dissection in the surgical management of stage I endometrial carcinomas]

The indication and extent of lymph node dissection in the surgical management of endometrial cancers remain highly controversial. Randomized studies are badly needed but will probably lack for the next years, considering the large sample size required to show a small difference in survival. The trend towards a reduction in the routine use of external radiation therapy weakens the argument that radiation therapy makes adequate lymph node dissection useless. The balance stays between the risk for node involvement and the expected complications rate of the procedure. Lymph node dissection is advised whenever there is a non-negligible risk of node metastasis in a patient at low surgical risk.

Paraneoplastic pemphigus is associated with the DRB1*03 allele

Pemphigus is a group of autoimmune blistering diseases caused by autoantibodies directed against keratinocyte adhesion molecules. Pemphigus vulgaris (PV) and pemphigus foliaceus (PF), in which autoantibodies bind, respectively, to desmoglein 3 and desmoglein 1, are strongly associated with HLA-class II DR4 and DR14 alleles. In paraneoplastic pemphigus (PNP), a rare variant associated with neoplasia, autoantibodies target proteins of the plakin family in addition to desmogleins 1 and 3. The presence of anti-desmoglein antibodies in all types of pemphigus raises the question of common molecular mechanisms of susceptibility, particularly similar MHC-class II allele associations, in the different forms of the disease. HLA-DRB1 typing was performed in 13 PNP patients and results were compared to those obtained from 84 healthy controls, 37 PV and 31 PF patients. Our data demonstrate a significant association of PNP with HLA-DRB1*03 allele which was found in 61.5% of the patients, whereas DRB1*04 and DRB1*14 appear not to be involved in PNP susceptibility. Therefore, the HLA-genetic background of PNP differs from that of other types of pemphigus, which suggests that distinct mechanism(s) initiate(s) the immunological response in this form of pemphigus.

Isolation of pig colonic crypts for cytotoxic assay of luminal compounds: effects of hydrogen sulfide, ammonia, and deoxycholic acid

Some colonic luminal molecules resulting from bacterial metabolism of alimentary or endogenous compounds are believed to exert various effects on the colonic epithelial cell physiology. We isolated surface epithelial cells and intact colonic crypts in order to test bacterial metabolites in the pig model, which is often considered relevant for extrapolation to the physiopathology of the human gastrointestinal tract. Using colonocytes isolated with EDTA, we found that the initial cell viability, estimated by the membrane integrity and oxidative capacity measurement, fell rapidly despite several experimental attempts to preserve it such as the use of a medium designed to increase the adherence of epithelial cells and of a coated extracellular matrix, the presence in the culture medium of the oxidative substrate butyrate, and the use of an inhibitor of the caspases involved in cell apoptosis. In contrast, using dispase and collagenase as proteolytic agents, we were able to obtain pig colonic crypts that maintain an excellent membrane integrity after 4 h. Using this preparation, we were able to test the presumably cytotoxic luminal compounds hydrogen sulfide, ammonia, and deoxycholic acid on colonic crypt viability. Of these, only deoxycholic acid was found to significantly alter the cellular membrane integrity. It is concluded that pig colonic crypts can be useful for the in vitro appraisal of the cytotoxic properties of luminal compounds.

A modified intussuscepted nipple in the Kock pouch urinary diversion: assessment of perioperative complications and functional results

OBJECTIVE

To assess the complications and continence of a modified intussuscepted nipple in Kock pouch urinary diversions.

PATIENTS AND METHODS

From February 1992 to December 2000, 40 patients (mean age 55.8 years, range 21-74) with bladder cancer (24), gynaecological tumours (eight) or previous lower tract reconstructive surgery (eight) underwent cystectomy and cutaneous continent urinary diversion using the Kock pouch procedure. The first 23 procedures (group I) used Henriet's technique, whereas a modified fixation of the intussuscepted efferent limb was applied in the last 17 (group II). Complications and functional results (focused on continence and the upper urinary tract) were reviewed.

RESULTS

The median (range) follow-up was 47.6 (10-124) months; one patient died 4 weeks after surgery. Early complications occurred in 11 (28%) and re-operation was required in two (5%). Of the late complications reported (38%), extussusception (8%) and efferent nipple prolapse (3%) only occurred in group I and required surgical revision. Late complications were minor (15%) including two asymptomatic refluxes and four with stoma sclerosis. The continence rate at 6 months in groups I and II were 78% and 94%, respectively (P = 0.13).

CONCLUSION

Efferent limb prolapse and extussusception of the Kock pouch were the main complications requiring surgical revision. Applying the modified nipple fixation the complications can be reduced and reservoir continence improved.

Tunisian endemic pemphigus foliaceus is associated with desmoglein 1 gene polymorphism

Desmoglein 1 is the target antigen and probably the initiating immunogen of the autoantibody response in pemphigus foliaceus (PF), a blistering autoimmune skin disease. We previously showed that the desmoglein 1 gene (DSG1) is polymorphic and that one of its variants is associated with the sporadic form of PF observed in France. Herewith, we report, based on a case-control analysis, that the same DSG1 polymorphism participates in susceptibility to the endemic form of PF seen in Tunisia and, thus, show that common genetic factors govern the breakage of tolerance to desmoglein 1 in different epidemiological and environmental situations.

Epistasis between DSG1 and HLA class II genes in pemphigus foliaceus

Pemphigus foliaceus (PF) is a rare and severe cutaneous autoimmune disease caused by autoantibodies directed against desmoglein 1 (DSG1), a desmosomal adhesion glycoprotein. We previously showed that the DSG1 gene is polymorphic and that a coding synonymous T/C single nucleotide polymorphism at position 809 is associated with PF. To determine whether the disease occurred as a consequence of complex genetic interactions, we simultaneously examined the contribution of major histocompatibility complex (MHC) class II and DSG1 polymorphisms to PF susceptibility. Our analysis performed in 31 PF patients and 84 healthy controls first confirmed the previously reported common DRB1*04 and DRB1*14 genetic background in PF and individualized DRB1*0102, DRB1*0402 and DRB1*0406, and DRB1*1404 as susceptibility MHC class II alleles in French Caucasian PF patients. It also showed that the C/C(809) genotype was associated with PF. Combined analysis of HLA class II and DSG1 polymorphisms with several distinct statistical methods including logistic regression, showed that the DRB1*04 allele and the C/C(809) genotype interact to confer a higher susceptibility to PF. These data demonstrate the role of epistasis between individual genes in PF susceptibility and illustrate the genetic complexity of organ-specific autoimmune diseases.

Comparative anatomical study of division of the ileocolic pedicle or the superior mesenteric pedicle for mesenteric lengthening

BACKGROUND

Lengthening of the mesentery by vascular division may be necessary to perform an ileal pouch-anal anastomosis without tension. The aim of this study was to compare, in fresh cadavers, the increase in mesentery length after division of the ileocolic pedicle (ICP) and the superior mesenteric pedicle (SMP).

METHODS

Total colectomy was performed in 12 fresh cadavers, which were then randomly divided into two groups. Pouch-anal anastomosis was performed with division of the ICP in one group of six cadavers and with division of the SMP in the other. The ileum was measured and the increase in length was recorded and compared statistically.

RESULTS

The mean(s.d.) increase in length was 3.0(0.8) cm after ICP division and 6.5(1.1) cm after SMP division (P < 0.001). The distance between the end of the ileum and the point giving the greatest length was 25.5(5.0) cm in the ICP group and 46.8(4.2) cm in SMP group (P < 0.001).

CONCLUSION

In fresh cadavers, the increase in mesenteric length was greater after SMP division than after ICP division, but if pouch-anal anastomosis is performed a short segment of small bowel must be removed.

Crohn's colitis: experience with segmental resections; results in a series of 84 patients

BACKGROUND

Colonic Crohn's disease can be treated surgically by total colonic resection or by segmental colonic resection. The aim of this study was to analyze the outcomes of patients treated by segmental colectomy for colonic Crohn's disease.

STUDY DESIGN

Among 413 patients undergoing operations for Crohn's disease, 84 had a segmental colectomy (cases of terminal ileitis with limited cecal involvement were not included). Postoperative complications, mortality, recurrence, and functional results were studied.

RESULTS

Eighty-four patients (51 women, 33 men), with a mean age of 34 years, underwent operation (right segmental colectomy: 55%; left segmental colectomy: 40%; associated right and left colectomy: 5%). A stoma was established in 27 patients (32%). Operative mortality was zero. Twelve patients (14%) had postoperative complications (including six cases of anastomotic leakage). The mean and median followup times were 111 and 104 months, respectively (range: 15 to 276 months) for the 82 patients with followup available. Thirty-six patients had to undergo reoperation, and the mean time to reoperation was 4.5 years. Twenty-six of these patients suffered colonic recurrence and were treated by total colectomy (n = 9) or new segmentary resection (n 17). The only factor that correlated with the risk of recurrence was youth. At the end of the study, 13 patients still had a stoma. Seventy-five percent of the patients without stoma had less than three bowel movements per day, and 80% were fully satisfied or satisfied,

CONCLUSIONS

There is no evidence of a higher risk of postoperative complications, surgical recurrence, or the requirement of a permanent stoma in patients suffering from colonic Crohn's disease who are treated according to a "bowel-sparing policy" compared with patients treated with more extensive resections published in the literature. Prospective randomized studies are needed to validate this observation.

Pemphigus is not associated with allotypic markers of immunoglobulin kappa

The kappa light chain constant region of immunoglobulins bears polymorphic markers involved in susceptibility to various autoimmune diseases. To determine whether it also contributes to the occurrence of pemphigus, a group of autoimmune blistering skin diseases owing to pathogenic autoantibodies, the genotypic frequencies of Km allotypes were evaluated in patients with pemphigus foliaceus or pemphigus vulgaris and ethnically-matched healthy controls in both Tunisia and France. No difference in the distribution of Km genotype or allele frequencies was observed between patients and controls in either countries. Therefore, Km allotypes do not appear to constitute a genetic factor contributing to pemphigus.

IGHV3-associated restriction fragment length polymorphisms confer susceptibility to bullous pemphigoid

OBJECTIVE

To determine whether the immunoglobulin heavy chain genes contribute to the occurrence of bullous pemphigoid (BP), polymorphisms of both the immunoglobulin constant IGHC and variable IGHV groups were studied in 100 Caucasian BP patients and 143 ethnically matched healthy individuals.

METHODS

To analyze the restriction fragment length polymorphism (RFLP) of the IGHG constant locus, a genomic immunoglobulin gamma 3 probe which detects polymorphisms in the gamma constant genes was hybridized to BstEII- or BamHI/SacI-digested germline DNA, while IGHV3 subgroup polymorphism was analyzed by hybridizing a cloned VH3 probe to EcoRI-digested DNA.

RESULTS

No difference in the frequencies of the genotypes defined by the constant probe was observed between patients and controls. Analysis of the RFLP obtained with the VH3 probe showed that within the range of 4.5 and 1.5 kb, the observed band pattern was composed of 8 monomorphic and 7 polymorphic bands. Among the latter, 4 allowed to define 10 different restriction patterns. One pattern was shown to be significantly less frequent in patients than in controls.

CONCLUSION

IGHV3 polymorphism might be a factor conferring susceptibility to BP.