Colon sparing resection versus extended colectomy for left-sided obstructing colon cancer with caecal ischaemia or perforation: a nationwide study from the French Surgical Association

AIM

It is not known whether patients with obstructive left colon cancer (OLCC) with caecal ischaemia or diastatic perforation (defined as a blowout of the caecal wall related to colonic overdistension) should undergo a (sub)total colectomy (STC) or an ileo-caecal resection with double-barrelled ileo-colostomy. We aimed to compare the results of these two strategies.

METHOD

From 2000 to 2015, 1220 patients with OLCC underwent surgery by clinicians who were members of the French Surgical Association. Of these cases, 201 (16%) were found to have caecal ischaemia or diastatic perforation intra-operatively: 174 patients (87%) underwent a STC (extended colectomy group) and 27 (13%) an ileo-caecal resection with double-end stoma (colon-sparing group). Outcomes were compared retrospectively.

RESULTS

In the extended colectomy group, 95 patients (55%) had primary anastomosis and 79 (45%) had a STC with an end ileostomy. In the colon-sparing group, 10 patients (37%) had simultaneous resection of their primary tumour with segmental colectomy and an anastomosis which was protected by a double-barrelled ileo-colostomy. The demographic data for the two groups were comparable. Median operative time was longer in the STC group (P = 0.0044). There was a decrease in postoperative mortality (7% vs 12%, P = 0.75) and overall morbidity (56% vs 67%, P = 0.37) including surgical (30% vs 40%, P = 0.29) and severe complications (17% vs 27%, P = 0.29) in the colon-sparing group, although these differences did not reach statistical significance. Cumulative morbidity included all surgical stages and the rate of permanent stoma was 66% and 37%, respectively, with no significant difference between the two groups. Overall survival and disease-free survival were similar between the two groups.

CONCLUSION

The colon-sparing strategy may represent a valid and safe alternative to STC in OLCC patients with caecal ischaemia or diastatic perforation.

Thirty-day mortality after emergency surgery for obstructing colon cancer: survey and dedicated score from the French Surgical Association

AIM

The aim was to define risk factors for postoperative mortality in patients undergoing emergency surgery for obstructing colon cancer (OCC) and to propose a dedicated score.

METHOD

From 2000 to 2015, 2325 patients were treated for OCC in French surgical centres by members of the French National Surgical Association. A multivariate analysis was performed for variables with P value ≤ 0.20 in the univariate analysis for 30-day mortality. Predictive performance was assessed by the area under the receiver operating characteristic curve.

RESULTS

A total of 1983 patients were included. Thirty-day postoperative mortality was 7%. Multivariate analysis found five significant independent risk factors: age ≥ 75 (P = 0.013), American Society of Anesthesiologists (ASA) score ≥ III (P = 0.027), pulmonary comorbidity (P = 0.0002), right-sided cancer (P = 0.047) and haemodynamic failure (P < 0.0001). The odds ratio for risk of postoperative death was 3.42 with one factor, 5.80 with two factors, 15.73 with three factors, 29.23 with four factors and 77.25 with five factors. The discriminating capacity in predicting 30-day postoperative mortality was 0.80.

CONCLUSION

Thirty-day postoperative mortality after emergency surgery for OCC is correlated with age, ASA score, pulmonary comorbidity, site of tumour and haemodynamic failure, with a specific score ranging from 0 to 5.

Influence of Impulsivity During Decision-making in Regular Cannabis Users

Introduction

Regular cannabis use is associated with cognitive impairments, including impaired decision making measured by the Iowa Gambling Task. The question remains whether the impulsivity measured in regular cannabis users may participate to impaired decision making. Interestingly, the Cambridge Gambling Task (CGT) is a computerized gambling task allows to differentiate risk taking and impulsivity when making a decision.

Aims

This study aims at separately exploring the impact of regular cannabis use on risk taking and impulsivity during decision making process.

Objectives

To do so, we compared the performance of regular cannabis users and healthy controls during the CGT.

Methods

Forty-three regular cannabis users (> 7 units/week) with a cannabis use disorder (CUD), 8 non-CUD regular cannabis users and 30 healthy controls were recruited. Decision-making was assessed using the CGT. The following outcomes were considered: Delay aversion score, Overall proportion bet, quality of decision making, risk taking and risk adjustment.

Results

The analysis on delay aversion score showed a group effect (F = 3.839, P = 0.026) but no effect on other CGT variables. This effect was explained by the fact that cannabis CUD users had a higher delay aversion score than healthy controls and non-CUD cannabis users.

Conclusions

In this study, CUD cannabis users had an increased impulsivity but no increase of risk taking and quality of decision-making. Future work should include the CGT with a clinical scale to evaluate impulsivity and a motor inhibition task to understand if the impairment observed relates to cognitive or motor abilities.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Assembly of Fe/S proteins in bacterial systems: Biochemistry of the bacterial ISC system

Iron/sulfur clusters are key cofactors in proteins involved in a large number of conserved cellular processes, including gene expression, DNA replication and repair, ribosome biogenesis, tRNA modification, central metabolism and respiration. Fe/S proteins can perform a wide range of functions, from electron transfer to redox and non-redox catalysis. In all living organisms, Fe/S proteins are first synthesized in an apo-form. However, as the Fe/S prosthetic group is required for correct folding and/or protein stability, Fe/S clusters are inserted co-translationally or immediately after translation by specific assembly machineries. These systems have been extensively studied over the last decade, both in prokaryotes and eukaryotes. The present review covers the basic principles of the bacterial housekeeping Fe/S biogenesis ISC system, and related recent molecular advances. Some of the most exciting recent highlights relating to this system include structural and functional characterization of binary and ternary complexes involved in Fe/S cluster formation on the scaffold protein IscU. These advances enhance our understanding of the Fe/S cluster assembly mechanism by revealing essential interactions that could never be determined with isolated proteins and likely are closer to an in vivo situation. Much less is currently known about the molecular mechanism of the Fe/S transfer step, but a brief account of the protein-protein interactions involved is given. This article is part of a Special Issue entitled: Fe/S proteins: Analysis, structure, function, biogenesis and diseases.

Understanding the roles of strictly conserved tryptophan residues in O2 producing chlorite dismutases

The chlorite dismutases (Clds) degrade ClO(2)(-) to O(2) and Cl(-) in perchlorate respiring bacteria, and they serve still poorly defined cellular roles in other diverse microbes. These proteins share 3 highly conserved Trp residues, W155, W156, and W227, on the proximal side of the heme. The Cld from Dechloromonas aromatica (DaCld) has been shown to form protein-based radicals in its reactions with ClO(2)(-) and peracetic acid. The roles of the conserved Trp residues in radical generation and in enzymatic function were assessed via spectroscopic and kinetic analysis of their Phe mutants. The W155F mutant was the most dramatically affected, appearing to lose the characteristic pentameric oligomerization state, secondary structure, and heme binding properties of the WT protein. The W156F mutant initially retains many features of the WT protein but over time acquires many of the features of W155F. Conversion to an inactive, heme-free form is accelerated by dilution, suggesting loss of the protein's pentameric state. Hence, both W155 and W156 are important for heme binding and maintenance of the protein's reactive pentameric structure. W227F by contrast retains many properties of the WT protein. Important differences are noted in the transient kinetic reactions with peracetic acid (PAA), where W227F appears to form an [Fe(IV)=O]-containing intermediate, which subsequently converts to an uncoupled [Fe(IV)=O + AA(+)˙] system in a [PAA]-dependent manner. This is in contrast to the peroxidase-like formation of [Fe(IV)=O] coupled to a porphyrin π-cation radical in the WT protein, which decays in a [PAA]-independent manner. These observations and the lack of redox protection for the heme in any of the Trp mutants suggests a tendency for protein radical formation in DaCld that is independent of any of these conserved active site residues.

[Port-site metastasis after retroperitoneal lymphadenectomy for endometrial adenocarcinoma]

Port-site metastasis is a rare but serious complication of laparoscopic surgery. The etiologies are poorly identified and multiple. We report the case of port-site metastasis after laparoscopic retroperitoneal lymphadenectomy for endometrial adenocarcinoma. In the literature, three cases of port-site metastasis after laparoscopic retroperitoneal lymphadenectomy are reported: two cases concerning cervical cancer and one case concerning a kidney cancer. To our knowledge, this is the only case about port site metastasis after laparoscopic retroperitoneal lymphadenectomy for endometrial adenocarcinoma.

Analysis of preoperative CT and peroperative evaluation as predictors of involvement of hepatic pedicle LN in patients operated for CRLM

375

Background: Approximately 20% of patients who undergo resection for colorectal liver metastases (CLM) have additional metastases present in hepatic pedicle lymph nodes (HPLN). Although LN status is a major prognostic factor, routine LN dissection is controversial. We evaluated the accuracy of preoperative CT scans and peroperative surgical assessment to determine if these methods could help determining which patients are at high risk for nodal metastases and should undergo lymphadenectomy.

Methods: Between 01-2008 and 06-2010, 76 consecutive patients who underwent liver resection and lymphadenectomy for CLM after neoadjuvant chemotherapy were enrolled in a prospective study. All patients had recent (<1 month) preoperative CT to evaluate their liver metastases and the presence, location, size and radiologic characteristics of LN were assessed. Peroperatively, the size and consistency of LN were evaluated by the surgeon. Surgeons and radiologists independently assessed LN involvement. Results were compared to the definitive pathologic examination.

Results: Among the 76 patients, 241 nodes were analyzed with a mean number of 3 (± 2) nodes removed per patient. Lymphadenectomy increased the surgical procedure by 20 minutes (12-25 min) and there was no specific morbidity or mortality related to LN clearance. Pathologic HPLN involvement was observed in 15 (20%) patients with a median number of 2 (1-6) metastatic nodes per patient. Peroperative assessment had a high negative predictive value (NPV) = 91% with a low positive predictive value (PPV) = 43%. CT scan assessment had also a NPV and PPV of 85% and 56%, respectively. When considering both peroperative and radiologic data, 27% of patients with pathologic LN involvement were not anticipated and 25% of patients who were node negative on pathologic examination had suspected LN involvement.

Conclusions: A selective strategy limiting HPLN clearance to high risk patients relies on information from preoperative CT scans and eroperative surgical assessment. Given that both modalities cannot accurately predict nodal pathologic status, routine HPLN dissection should be performed in patients who undergo resection of CRLM.

No significant financial relationships to disclose.

[Surgical techniques of appendectomy for acute appendicitis]

Over the last 20 years, the treatment of acute appendicitis has been transformed by the development of the laparoscopic approach. And yet the net value of this approach continues to be debated. Laparoscopic appendectomy is associated with a lower complication rate and a shorter period of disability in the general population. While operative costs are higher, the global cost of laparoscopic appendectomy is lower than for open appendectomy. There is a somewhat higher rate of abdominal abscess for the laparoscopic route. Laparoscopic appendectomy shows clear advantages in obese patients and in those with gangrenous or ruptured appendicitis. The laparoscopic approach is contra-indicated during pregnancy due to a higher incidence of miscarriage. Treatment of the appendiceal stump by ligature decreases the expense associated with the use of a surgical stapler. When Meckel's diverticulum is encountered during appendectomy, it should be removed in all pediatric patients; in adults, Meckel's diverticulectomy in adults should be performed only for clear-cut pathology. Surgeons continue to innovate and refine appendectomy techniques but many questions remain to be answered.

WITHDRAWN: Quelle technique chirurgicale pour une appendicectomie pour appendicite aigue ?

The Publisher regrets that this article is an accidental duplication of an article that has already been published, doi:10.1016/j.jchir.2009.09.002. The duplicate article has therefore been withdrawn.

[Limited pancreatic resections for intraductal papillary mucinous neoplasm]

INTRODUCTION

For non-invasive intraductal papillary and mucinous neoplasm (IPMN) with limited extent, pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) seem excessive due to the risk of pancreatic insufficiency. Enucleation (EN) or medial pancreatectomy (MP) are not commonly performed for IPMN. The aim of this study was to evaluate the feasibility and results of EN and MP for non-invasive IPMN.

PATIENTS AND METHODS

Of 249 patients with IPMN, we attempted a limited resection in 50 (20%) EN (n=31) or MP (n=20) with routine intra-operative frozen section pathology. One attempted EN was converted to MP. Indications for surgery were pain/pancreatitis (44%), suspicion of main duct involvement (28%), mural nodules in branch duct (14%), branch duct>30 mm (8%) or suspicion of mucinous cystadenoma (6%). Follow-up clinical assessment and MRI were performed on a yearly basis.

RESULTS

Of the 31 attempted enucleations, 5 (13%) were immediately converted (4 PD, 1 MP) due to technical reasons (n=3) or due to findings on frozen section (n=2). At definitive pathological examination (accuracy of frozen sectioning=98%), branch ducts were involved by mild (n=21), moderate (n=7) or high grade dysplasia (n=2). One patient underwent a double EN. Of 20 attempted medial pancreatectomies, 8 (40%) required additional segmental resection due to significant IPMN lesions at pancreatic margins; 3 of the additional resection margins were tumor-free, and 5 were involved by IPMN (4 conversions to PD or DP, one contra-indication to PD). Overall, 49 pancreatic margins were analyzed by frozen sectioning with 98% accuracy. Resected specimens of 16 MP showed involvement by mild (n=7), moderate (n=7) or high grade dysplasia (n=2). There was no postoperative mortality. Median length of stay was 21 and 30 days respectively after EN and MP. Pancreatic fistula rate was 54% and 81% respectively after EN and MP. Three patients underwent early re-operation for hemorrhage. Overall median follow-up was 24 months (3-121). All patients are alive, 2 patients (5%) have presented with recurrent pain and 4 have developed tumor recurrence on imaging follow-up (4/33=12%). Two patients (5%) developed de novo diabetes (one after EN combined with DP) and a third patient developed worsening of pre-existing diabetes plus exocrine insufficiency. No patient had surgery for recurrence.

CONCLUSIONS

EN and MP are feasible for non-invasive IPMN. Their significant early morbidity is counterbalanced by low rates of both long-term functional disorders and tumor recurrence.

[Pelviperineoscopy. Preliminary study of feasibility on cadavers]

OBJECTIVE

The traditional access of perineum for the treatment of the pelvic organ prolapse by vaginal route is probably responsible for the risk of mesh exposure and a longer convalescence. So, endoscopic access to perinemeum needs to be evaluated.

PATIENTS AND METHODS

Feasibility study on cadavers. Details of the procedure: opening of the pararectal space by digital dissection first after incision on the level of the posterior commissure. Introduction of an optical trocart to the level of the perineum incision; dissection of pararectal space with optics and CO(2); individualization of the various elements; installation of a transobturator trocart and a transgluteal trocart; dissection of the rectovaginal septum and visualization of the sacrospinous ligament and pudendal nerve. The measured variables were: operational incidents, possibility of creation of working space, dissection of the rectovaginal septum; finally, visualization of the sacrospinous ligament and pudendal pedicle.

RESULTS

On the 4 studied cadavers, we could carry out a dissection of pelvirectal space in all the cases. On the 8 pararectal fosses, in all the cases we could carry out a cavity of dissection and to open the recto vaginal septum, visualization of the sacrosciatic ligament and pudendal pedicle was possible in 6 cases out of 8. There were one rectal injury, two vaginal injuries and one lesion of the pudendal pedicle.

DISCUSSION AND CONCLUSION

This endoscopic access allows in the majority of cases to see the structures necessary to the realization of a vaginal sacrospinofixation or the installation of posterior mesh without a colpotomy and a traumatic exposure. The incidents are probably due to our inexperience and should disappear in time. The pelvi-perineoscopy is an endoscopic access of perineum which should be evaluated.

Transvaginal ultrasound measurement of cervical length and efficacy of misoprostol in first-trimester pregnancy failure

OBJECTIVE

The aim of this study was to assess the role of cervical length measurement in predicting successful treatment, by misoprostol administration, of early (first-trimester) pregnancy failure.

METHOD

A prospective study was conducted of all patients who agreed to medical treatment of pregnancy failure. Cervical length and other sonographic variables were measured using pelvic ultrasound before medical treatment began. Measurements were compared between the group with successful medical treatment and the group in whom treatment failed.

RESULTS

In 125 women included in the study, the success rate of misoprostol treatment was 64.8%. There were no significant differences between the groups with successful and failed treatment for cervical length (29.9 +/- 9.3 vs. 30.4 +/- 6.8 mm, P = 0.75), distance between gestational sac and 'virtual' cervical internal os (23.9 +/- 13 vs. 26.6 +/- 13 mm, P = 0.26), crown-rump length (8.7 +/- 9.7 vs. 6.7 +/- 8.6 mm, P = 0.25), or gestational sac diameter (31.3 +/- 14 vs. 30.1 +/- 15 mm, P = 0.73).

CONCLUSION

Cervical length does not predict the success of misoprostol treatment of first-trimester pregnancy failure.

[Comparative evaluation of the Joel-Cohen cesarean section versus the transrectal incision]

OBJECTIVE

The aim of this study was to compare the Joel-Cohen method for cesarean section to the traditional transrectal incision.

METHOD

Fifty-two patients requiring a caesarean section were enrolled in this prospective study. Overall morbidity and post-operative pain was assessed. Four surgeons participated to this study, each included 13 patients. The main judgement criterion was post-operative pain on the first day.

RESULTS

Post-operative pain on the first day was less important (50 vs 23% p=0.04) in Joel-Cohen's. This method was shorter compared to the transrectal incision (33.6+6.4 min vs 51.2+8 min p<0.0001). There was no difference in overall morbidity between the two groups.

CONCLUSION

Joel-Cohen's method decrease post-operative pain and is a shorter procedure compared to the transrectal incision.

[Impact of the surgical route on staging and outcome of early borderline ovarian tumors]

OBJECTIVE

To assess the impact of the surgical route on the management and outcome of early borderline ovarian tumors (BOT).

PATIENTS AND METHODS

We have retrospectively analysed BOT operated on between January 1st 1985 and December 31st 2001. We included cases with clinical stages Ia to Ic. We compared the prevalence of deleterious acts according to the surgical access, as well as the quality of staging. Univariate and multivariate analysis assessed the impact of factors on quality of staging. Survival was also compared according to the initial surgical access. Data were computed and analysed using SPPS 7.5 and STATA 8.

RESULTS

118 cases have been included, 48 (41%) have been operated on by laparoscopy, 54 (45%) by laparotomy and 16 (14%) had a conversion. A conservative treatment has been done in 57% of patients, with increased frequency in case of laparoscopy (P<0.05) and in aged patients (P<0.001). A tumor rupture occurred in 9% of cases, without difference between accesses (P=0.1). A bag was used for the specimen delivery in only 40% of cases of laparoscopy. Most of patients (73%) had an incomplete staging. Year of treatment, and a radical treatment were associated with a better staging. Survival curves showed no detrimental effect of laparoscopy.

DISCUSSION AND CONCLUSION

Despite an incomplete staging, this series does not show any detrimental effect of laparoscopy on the outcome of early BOT.

Impact of initial surgical access on staging and survival of patients with stage I ovarian cancer

The aim of this study was to compare staging by laparoscopy and laparotomy, and to compare survival in patients with laparoscopy versus laparotomy as the first surgical access. We conducted a retrospective analysis of patients with stage I ovarian cancer treated surgically between 1985 and 2001, and we included those patients with stage I epithelial cancer for whom follow-up data were available. For each patient, we recorded whether initial surgical staging was by laparoscopy or by laparotomy, the procedures done at initial staging surgery, and the outcomes. The data were evaluated by analysis of variance, Chi-square test or Fisher's exact test, logistic regression, Cox model, and log-rank test, using SPSS 7.5 and STATA. Initial staging was by laparoscopy in 34 patients, laparotomy in 114 patients, and laparoscopy converted to laparotomy in 30 patients. In the laparotomy group, patient age was significantly greater and tumor size significantly larger, as compared to the laparoscopy group. Staging after first surgery was often inadequate; most notably para-aortic lymph node dissection was done in 0% of laparoscopy patients, 18% of laparotomy patients, and 33% of conversion patients. Restaging surgery has been indicated in 88% of laparoscopy patients, 48% of laparotomy patients, and 46% of conversion ones. After a mean follow-up of 40 months, survival rates were not significantly different among the three patient groups. No deleterious influence of laparoscopy as first surgical access was detected by univariate or multivariate analysis. Despite of inaccurate radicality and staging during initial laparoscopy, this study found no harmful influence of laparoscopy as first initial access on outcomes of patients with stage I ovarian cancer.

[Vaginoscopic hysteroscopy]

Vaginoscopic hysteroscopy permits to avoid several painful gestures of classical office hysteroscopy. The aim of this article is to describe the advantages such vaginoscopic approach. Six studies were thus selected, dealing with vaginoscopic hysteroscopy. The diameter of the hysteroscope, always a rigid one, was between 3.5 and 5 mm, and CO(2) or saline infusions were indifferently used. Failure rate is inferior to 5%. One study, comparing pain induced by vaginoscopic versus classical hysteroscopy, concluded that vaginoscopic approach was less painful.

[Cervical ripening using misoprostol before hysteroscopy]

Cervical ripening with misoprostol is performed before office or operative hysteroscopy. Aim of this review is to evaluate benefits of cervical ripening with misoprostol before hysteroscopy . Ten studies were selected concerning office or operative hysteroscopy. Cervical ripening with misoprostol seems to be not useful for office hysteroscopy performed with minihysteroscope. Interest of misoprostol in menopausal women with traditional office hysteroscope is debatable. Risk of cervical tear during operative hysteroscopy seems to be reducing with misoprostol. However, interest of misoprostol was not found in all studies. Data were not sufficient to determine adequate dose of misoprostol, time and mode of administration. However, vaginal administration is preferable.

Résultats de la sacro-spino-fixation dans le traitement des prolapsus après hystérectomie

OBJECTIVE

To evaluate results of sacrospinous ligament fixation in the treatment of posthysterectomy prolapse.

PATIENTS AND METHODS

Between September 1990 and September 2002, 92 women (mean age 64.8 years, range 45 to 92 years) underwent sacrospinous ligament fixation following total hysterectomy (82.6%) or subtotal hysterectomy (17.4%); 96.7% had a menopausal status, and 21.7% used hormone replacement therapy. 48.9% of the patients had a history of surgery for prolapse (and/or urinary incontinence), and 21.7% had associated symptoms of stress urinary incontinence. In all cases, sacrospinous ligament fixation was performed under visual control using conventional stitch. Sacrospinous ligament fixation was combined with the following procedures: anterior vaginal repair (n=31), additional incontinence surgery (n=11), cervical amputation (n=11), levator myorrhaphy (n=61). Main outcome measures were intraoperative complications, postoperative complications, anatomic and functional outcome.

RESULTS

Complications were represented by 1 vaginal hematoma (related to sacrospinous fixation), 1 bladder injury, 1 ureteral injury, 3 acute urinary retentions. With a mean follow-up of 47 months (range: 12-156), 12 patients (13.5%) had failure of sacrospinous ligament fixation and 9 required additional procedures, during the first year of follow-up. 14 patients (15.7%) had postoperative cystocele, with 1 case of third-degree cystocele treated with sub-bladder prosthesis by the vaginal route.

CONCLUSION

We noted low rates of major complications and sacrospinous ligament fixation in posthysterectomy prolapse appears to give satisfactory long-term results.

Diagnostic de torsion d'annexe : existe-t-il des signes prédictifs de nécrose ?

OBJECTIVE

To determine the most relevant findings for diagnosis of adnexal torsion and predictive factors of adnexal necrosis.

PATIENTS AND METHODS

Clinical, biological, ultrasound, pathologic and surgical findings in surgically confirmed cases of adnexal torsion treated over a five-year period in a gynaecologic emergency department were retrospectively reviewed.

RESULTS

A total of 52 cases of adnexal torsion were studied. Abdominal pain was present in 80.8%, vomiting in 13.5% and fever only in 9.6%. Leukocytosis was noted in 19 (36.5%). The most frequent ultrasound findings were ovarian enlargement in 22 patients (42.3%), ovarian cysts in 26 (50%), and hyperechogenic parenchyma with follicles along the periphery of the ovary in 13 (25%). Age over 40 years and a delay to surgery longer than 10 hours were significantly associated with diagnosis of adnexal necrosis.

DISCUSSION AND CONCLUSION

Prompt diagnosis of adnexal torsion requires a combination of clinical, biological and radiological evidence. No predictive factors of necrosis are found. Risk of adnexal torsion is potentially increased by waiting period for surgery and patient's age.

[Sacrospinous colpopexy complications]

OBJECTIVE

To evaluate complications of sacrospinous ligament fixation.

DESIGN

Monocentric retrospective study.

SETTING

Department of Obstetrics & Gynecology, La Conception University Hospital, Marcella.

PATIENTS AND METHODS

Between January 1991 and September 2002, 277 women (mean age 64.9 years, range 37 to 92 years) underwent a sacrospinous ligament fixation; 91% had a menopausal status, and 15.5% used hormone replacement therapy. 33.2% of the patients had prior hysterectomy, 28.9% had a history of surgery for prolapse, and 18.8% had associated symptoms of stress urinary incontinence. In all cases, sacrospinous ligament fixation was performed under visual control using conventional stitch. Sacrospinous ligament fixation was combined with the following procedures: anterior vaginal repair (N =137), additional incontinence surgery (N =31), vaginal hysterectomy (N =137), levator myorraphy (N =203).

MAIN OUTCOME MEASURES

Intraoperative complications, postoperative complications, long-term painful symptoms.

RESULTS

Intraoperative complications were represented by 1 case of vascular wound and four rectal injuries. Main postoperative complications were vaginal haematomas (N =6) and abscesses (N =2). Long-term symptoms were perineal pain, sciatic neuralgia, and dyspareunia.

DISCUSSION AND CONCLUSION

There was no surgical mortality, and we noted low rates of major complications. Sacrospinous ligament fixation assumes high priority in our therapeutic regimen.

[Results of hysteroscopic myomectomy]

Main symptoms related to submucous fibroids are menorrhagia, infertility, and postmenopausal bleeding. First experiences of hysteroscopic transcervical resection of fibroids have been published by Neuwirth in the late seventies. Reports with long-term follow-up in patients with abnormal uterine bleeding are available. After a follow-up period of five years and more, results are satisfactory in 70-85% of the patients. Intramural class 2 and larger fibroids (> 4 cm) constitute the limits of the endoscopic technique. Prior to hysteroscopic myoma resection, pretreatment with GnRH agonists may be indicated in selected cases (large myomas, patients suffering from secondary anemia). Repeat resection is an option after failed primary hysteroscopic operation and may reduce the hysterectomy rate. In infertile women with submucosal or intracavitary fibroids, pregnancy and delivery rates are increased after hysteroscopic myomectomy. Operative hysteroscopy is also safe and effective in controlling persistent postmenopausal bleeding. To conclude, hysteroscopic resection is the gold standard for the treatment of symptomatic submucous fibroids.

[Oxygen embolism after hydrogen peroxide irrigation of a breast abscess]

We report the case of oxygen embolism after inappropriate hydrogen peroxide irrigation of a breast abscess in a young patient. The issue proved to be both rapid and favourable.

Avancées dans la physiopathologie de la pré-éclampsie : place de la réponse inflammatoire

Inflammatory response is a major component in physiopathology of preeclampsia and intra-uterine growth retardation. Endothelium is a main connection between placental ischemia and clinical manifestations during vascular pregnancy complications. In this review recent findings concerning inflammatory response and its links with endothelium are reported. Studies concerning isolated intra-uterine growth retardation confirm the hypothesis of a similar pathophysiology with an activation confined to utero-placental bed or at a lower level. Current information on oxidative stress, atherosclerosis, and apoptosis in vascular pregnancy complications are available in this review. These concepts offer innovative possibilities of treatment.

Complications during set-up procedures for laparoscopy in gynecology: open laparoscopy does not reduce the risk of major complications

OBJECTIVE

To compare the risk of major complications during the set-up procedures for laparoscopy according to whether the classic technique (creation of the pneumoperitoneum followed by introduction of the optics trocar) or open laparoscopy is used.

METHODS

Comparison was made of two retrospective series each carried out in a department promoting one of the two techniques. The setting was a university-affiliated hospital. Two groups of patients were compared: group A, classic laparoscopy, n = 8324; group B, open laparoscopy, n = 1562. We investigated the set-up procedures of operative laparoscopy according to the rules of classic or open laparoscopy.

RESULTS

The risk of failure requiring conversion to laparotomy is significantly higher in the group of patients who underwent open laparoscopy [three cases (0.19%) vs. 0 case (0.0%); p = 0.004]. The risk of major complications is comparable in the two groups [group A, four cases (0.05%) vs. group B, three cases (0.19%); p = 0.08]. In the classic laparoscopy group there were four major complications: one injury to the aorta and three bowel injuries. In the open laparoscopy group there were three major complications: two bowel injuries and one postoperative occlusion.

CONCLUSIONS

Open laparoscopy does not reduce the risk of major complications during the set-up procedures for laparoscopy. Randomized prospective trials are indispensable for comparing the risks involved with the classic technique and those of open laparoscopy.

Stage I ovarian cancer: comparison of laparoscopy and laparotomy on staging and survival

OBJECTIVE

The aim of this study was to compare staging accurateness as well as survival when managing early ovarian cancers by laparoscopy or laparotomy.

MATERIAL AND METHODS

We have conducted a retrospective and multicentric study in France. Only Stage I ovarian epithelial cancers operated on from January 1, 1985 to December 31, 1999 were taken into account. Respondents had to fill in a form detailing in each case the surgical access; the surgical acts performed during the initial intervention as well as data on the patient's follow-up. Lack of follow-up or final Stage > I were considered as exclusion criteria. Data were recorded and analysed with SPSS 7.5 and STATA (Stata statistical sofware 7.0). (ANOVA, chi-square test or Fisher's exact test and log-rank test).

RESULTS

105 cases were included: 14 patients were exclusively operated on by laparoscopy (group 1), 13 other patients were subjected to a conversion from laparoscopy to laparotomy (group 2) and 78 patients exclusively underwent laparotomy (group 3). Patients in group 3 were significantly more frequently postmenopausal and had larger lesions. Cyst rupture was rare during laparoscopy (21%) and the use of an endobag was achieved in only 21% of the patients in group 1. Radical treatment was significantly more frequent in group 3 when compared to group 1 (67% vs 23%, p < 0.05). Laparoscopy was not adequate for staging since no lymphadenectomy was carried out by this approach. However, only 27% of patients subjected to an open approach underwent lymphadenectomy and omentectomy. The outcome in terms of survival was similar in the three groups with a mean follow-up period of 1,221 days (+/- 832) (p = 0.1).

CONCLUSION

Laparoscopic management of early ovarian cancer is poorly efficient in staging although disease-free survival does not seem to be affected. Further evaluation of laparoscopy in this indication is needed.

Port site metastasis after laparoscopy for uterine cervical carcinoma

BACKGROUND

Aim of this study was to review cases reported of port-site recurrence (PSR) after laparoscopy for uterine cervical carcinoma.

METHODS

A Medline computer database search from January 1980 to September 2002.

RESULTS

We reported 13 cases published of PSR after laparoscopy for cervical carcinoma. The majority of them were squamous carcinoma (9/13 at least, 69%) and initial staging of disease was Ib (7/13 (54%)). Median of interval between laparoscopy and diagnostic of PSR was 7 months (min 1.5 month, max 48 months). Of 10 cases of laparoscopy with lymphadenectomy, in three cases (30%) nodes were not involved. PSR developed at the port through which tissues was extracted in four cases (30.1%) or another port in five cases (38.5%). At the time of PSR, five patients (38.5%) were free of disease.

CONCLUSIONS

PSR were reported after laparoscopy for lymphadenenectomy with or without hysterectomy and with or without node involvement. In some cases, umbilical metastases should not be systematically diagnosed as PSR and a diagnosis of Sister Mary Joseph's nodule may be discussed.

[Conservative treatment of placenta accreta]

OBJECTIVE

Examination of modalities and results of conservative treatment of placenta accreta.

MATERIAL AND METHOD

Ten-year hospital records were reviewed, with analysis of patients who had diagnosis of placenta accreta associated with conservative treatment.

RESULTS

During the study period, 21259 deliveries were registered, with an incidence of placenta accreta of 1 per 1 000 deliveries (n=23). Conservative treatment was applied in 13 patients. All of them had factors commonly associated with placenta accreta: prior cesarean sections (7/13), prior curettage or endouterine surgery (11/13), placenta praevia (11/13). Antenatal diagnosis was performed in only 64% of the cases (n=7). In our conservative strategy, placenta accreta was always left in situ, with an associated treatment in most of cases (n=10): Bilateral hypogastric artery ligation (n=7), medical treatment with methotrexate (n=5), uterine artery embolization (n=2). There was no case of maternal mortality. Conservative treatment was successful in 11 patients. It failed in 2 cases: hysterectomy was performed in one case for life-threatening hemorrhage, and in the other case for post-embolization uterine necrosis. The morbidity described was blood transfusion (n=7), endometritis (n=1), and one late hemorrhage with expelling necrotic tissue. Afterwards, 2 women became pregnant: one miscarriage and one normal term delivery.

CONCLUSION

Conservative treatment of placenta accreta appears to be a efficient way to preserve fertility. Antepartum diagnosis should be improved among patients with a high risk of placenta accreta in order to optimize conservative strategy.

[Complications of operative hysteroscopy]

OBJECTIVES

Assess the prevalence and severity of the various complications of operative hysteroscopy, the context in which they occur and the treatments proposed.

METHOD

A single-center observational study from 1/1/90 to 1/1/99 including 2,116 surgical hysteroscopies (resection of a fibroma (782) or polyp (422), section of a septate uterus (199), synechia uteri (90) and endometrectomy (623)).

RESULTS

There were 74 complications (3.5%). The most frequent was uterine perforation (34 cases (1.61%)). There were 13 cases of haemorrhage (0.61%), 16 cases of post-surgical fever (0.76%) and 11 metabolic complications (0.47%). Synechia uteri was the surgical intervention with the greatest risk of complications.

CONCLUSIONS

The complications of surgical hysteroscopy are rare and relatively benign. Uterine perforation appears to predominate. In our study, the risk of complication was enhanced in the case of synechia uteri.