To drain or not to drain: A propensity score analysis of abdominal drainage after colorectal surgery for endometriosis

AIM

To assess the benefit of prophylactic abdominal drainage (AD) after colorectal surgery for endometriosis.

METHODS

We conducted a retrospective study of 215 patients who underwent colorectal surgery for endometriosis using a mini-invasive approach in our center from February 2019 to July 2023. A propensity score matched (PSM) analysis (1:1 ratio) identified two groups of patients with similar characteristics. Postoperative outcomes were then compared.

RESULTS

In the unmatched cohort, 151 patients (70 %) had AD at the end of surgery and 64 (30 %) did not. Clinical characteristics and surgical procedures were comparable between the groups after PSM. After PSM, AD was associated with a longer hospital stay (p < 0.001) and a greater number of postoperative complications (p = 0.03). There were no differences for readmission, repeat surgery, or severe postoperative complications.

CONCLUSION

In this retrospective cohort of patients undergoing colorectal resection for endometriosis using a mini-invasive approach, prophylactic AD was not found to be beneficial.

Outcomes of discoid excision and segmental resection for colorectal endometriosis: robotic versus conventional laparoscopy

Surgery for deep endometriosis with colorectal involvement is an option after medical treatment failure. Over the past decade, robotic laparoscopy has emerged as an alternative to conventional laparoscopy. We aimed to evaluate surgical outcomes of robotic versus conventional laparoscopy for discoid excision and segmental resection. From 2019 to 2023, we conducted a retrospective cohort study of 152 consecutive patients with colorectal endometriosis who underwent robotic or conventional laparoscopy for discoid excision and colorectal resection. Ninety of the patients 152 underwent robotic surgery and 62 conventional laparoscopy. The mean total surgical room occupancy and operating times were longer in the robotic group: 270 ± 81 min vs 240 ± 79 min, p = 0.010, and 216 ± 78 min vs 190 ± 76, p = 0.027, respectively. The mean intraoperative blood loss, and the incidence of intra- and postoperative complications (according to Clavien-Dindo classification) were similar in the two groups. The mean hospital stay was greater after conventional laparoscopy (8 ± 5 vs 7 ± 4 days; p = 0.03), and the rate of persistent voiding dysfunction was higher in the conventional group (9/11, 25% vs 2/11, 5%; p = 0.01). A higher incidence of persistent voiding dysfunction was also observed after segmental resection by conventional laparoscopy (25% vs 4.8%, p = 0.01). Our results support the use of robotic surgery as an alternative to conventional laparoscopy for discoid excision and segmental resection for colorectal endometriosis.

Discoid excision for colorectal endometriosis associated infertility: A balance between fertility outcomes and complication rates

OBJECTIVE

The objective of our study was to study the impact of discoid excision for deep endometriosis (DE) with colorectal involvement on fertility outcomes.

METHODS

49 patients with a desire for pregnancy treated with discoid excision for colorectal endometriosis in our endometriosis expert center between January 2015 and August 2020 were selected from our prospectively maintained database. Indications for surgery were either infertility and / or pelvic pain. Postoperative complications were graded according to the Clavien-Dindo classification. Fertility outcomes, both spontaneous and post-ART pregnancies, were analyzed.

RESULTS

Among the 49 patients who underwent discoid excision exclusively (no other digestive resection) with a desire to conceive, 25 had a pregnancy after surgery and 24 did not. Double discoid excision was performed in 6.1 % of the cases (3/49). A colpectomy was performed in 12.2 % of the patients (6/49), and a protective stoma in 12.2 % (6/49). Fenestration of endometriomas was performed in 28.6 % of the patients (14/49), and parametrectomy in 40.8 % (20/49). The postoperative complication rate was 24.5 % (12/49) including 10.2 % (5/49) grade I, 12.2 % (6/49) grade II, and 2 % (1/49) grade III. Prior to surgery, 28 (57.1 %) patients had infertility including 13 (52 %) that successfully conceived following surgery and 15 (62.5 %) that remain infertile. Spontaneous pregnancy was achieved in 60 % (15/25) of infertile patients' prior surgery. The live-birth rate in patients conceiving spontaneously was 75 % (12/16).

CONCLUSION

Our results support that discoid excision is safe and associated with good fertility outcomes. Whether first-line surgery using discoid excision is superior to first-line ART remains to be determined.

Changes in hospital consumption of opioid and non-opioid analgesics after colorectal endometriosis surgery

The aim of this study was to analyze postoperative consumption of analgesics during hospitalization following colorectal surgery for endometriosis. We conducted a retrospective study at Tenon University Hospital, Paris, France from February 2019 to December 2021. One hundred sixty-two patients underwent colorectal surgery: eighty-nine (55%) by robotic and seventy-three (45%) by conventional laparoscopy. The type of procedure had an impact on acetaminophen and nefopam consumed per day: consumption for colorectal shaving, discoid resection, and segmental resection was, respectively, 2(0.5), 2.1(0.6), 2.4(0.6) g/day (p = 10-3), and 25(7), 30(14), 31(11) mg/day (p = 0.03). The total amount of tramadol consumed was greater following robotic surgery compared with conventional laparoscopy (322(222) mg vs 242(292) mg, p = 0.04). We observed a switch in analgesic consumption over the years: tramadol was used by 70% of patients in 2019 but only by 7.1% in 2021 (p < 10-3); conversely, ketoprofen was not used in 2019, but was consumed by 57% of patients in 2021 (p < 10-3). A history of abdominal surgery (OR = 0.37 (0.16-0.78, p = 0.011) and having surgery in 2020 rather than in 2019 (OR = 0.10 (0.04-0.24, p < 10-3)) and in 2021 than in 2019 (OR = 0.08 (0.03-0.20, p < 10-3)) were the only variables independently associated with the risk of opioid use. We found that neither clinical characteristics nor intraoperative findings had an impact on opioid consumption in this setting, and that it was possible to rapidly modify in-hospital analgesic consumption modalities by significantly reducing opioid consumption in favor of NSAIDS or nefopam.

Value of non-coding RNAs to assess lymph node status in cervical cancer

Cervical cancer (CC) is the fourth cancer in women and is the leading cause of cancer death in 42 countries. Lymph node metastasis is a determinant prognostic factor, as underlined in the latest FIGO classification. However, assessment of lymph node status remains difficult, despite the progress of imaging such as PET-CT and MRI. In the specific setting of CC, all data underlined the need for new biomarkers easily available to assess lymph node status. Previous studies have underlined the potential value of ncRNA expression in gynecological cancers. In this review, we aimed to evaluate the contribution of ncRNAs in tissue and biofluid samples to determine lymph node status in CC with potential impact on both surgical and adjuvant therapies. In tissue samples, our analysis found that there are arguments to support the role of ncRNAs in physiopathology, differential diagnosis from normal tissue, preinvasive and invasive tumors. In biofluids, despite small studies especially concerning miRNAs expression, promising data opens up new avenue to establish a non-invasive signature for lymph node status as well as a tool to predict response to neo- and adjuvant therapies, thus improving management algorithm of patients with CC.

First-line surgery vs first-line ART to manage infertility in women with deep endometriosis without bowel involvement: A multi-centric propensity-score matching comparison

OBJECTIVE

To compare first-line surgery with first-line assisted reproductive techniques (ART) in infertile women with deep infiltrating endometriosis (DIE) without colorectal involvement.

STUDY DESIGN

A retrospective comparative cohort study with a propensity-score matching analysis, in four tertiary-care referral centers. The population was infertile women with DIE without colorectal involvement. The patients were managed either by first-line surgery followed by spontaneous conception attempts and/or ART, or by first-line ART. 284 patients were extracted from the databases. After matching, 92 patients were compared in each group. Clinical pregnancy rates (PR) and live-birth rates (LBR) were the primary outcomes, and cumulative pregnancy rate (CPR) and cumulative live birth rate (CLBR) were the secondary outcomes.

RESULTS

The mean number of IVF-ICSI cycles per patient was 1.4, with a significant difference between the groups: 1.6 in the first-line ART group and 1.2 in the first-line surgery group (p = 0.006). The PR was significantly higher in the first-line surgery group (72 % vs 35 %; p < 0.001). In the first-line surgery group, non-ART pregnancies occurred in 18 % (17/92) while no non-ART pregnancies was noted in the first-line ART group. The LBR was significantly higher in the first-line surgery group (61 % vs 24 %; p < 0.001). After ART, the CPR were 72 % (47/67) in the first-line surgery group, and 35 % (32/92) in the first-line ART group (p < 0.001).

CONCLUSION

After matching, our results support that first-line surgery offer higher pregnancy and live-birth rates than first-line ART in patients with DIE without colorectal involvement.

Prognosis of triple-negative breast cancer associated with pregnancy: A propensity score-matched analysis from the French CALG (Cancer Associé à la Grossesse) network

Introduction

Triple-negative (TN) breast cancer represents one third of pregnancy-associated breast cancers (PABC). The aims of the current study were to describe oncological and obstetrical outcomes of patients with TN-PABC and to compare their prognosis with TN-non-PABC patients using a propensity score.

Materials and methods

Between January 2005 and December 2020, data of patients with histologically proven TN-PABC were collected and compared with data of TN-non-PABC patients under the age of 46 years diagnosed during the same period using a propensity score (PS).

Results

After PS matching (tumor size and lymph node involvement),there were 59 patients in each group. The median follow-up was 14 months (IQR 4.8–40.1) for the TN-PABC group and 60 months (IQR 30.7–101.4) for the TN-non-PABC group. Eight recurrences occurred in the TN-PABC group and 10 in the TN-non-PABC group (adjusted OR (AOR) = 0.60 (0.21–1.60), HR (Cox adjusted model- AHR) = 1.25 (0.53–2.94)). Two patients died in the TN-PABC group, and six in the TN-non-PABC group with an AOR = 0.23 (0.03–1.01) and an AHR = 0.58 (0.12–2.69). All the patients diagnosed during the second (n = 17) and third trimesters (n = 28) continued their pregnancies, with a median term at delivery of 38 WG (IQR 36–39). All patients gave birth to healthy newborns.

Conclusion

Although the TN subtype is associated with poor prognosis in pregnant patients due to advanced stage at diagnosis and high lymph node involvement, our PS-matched case-control study showed that pregnancy per se does not worsen the prognosis in terms of recurrence-free and overall survival.

•

Triple-negative breast cancer are associated with poor prognosis.

•

Breast cancers occurring during pregnancy differ from those occurring in the post-partum period.

•

Pregnancy per se does not worsen the prognosis in triple-negative breast cancer.

A short anogenital distance on MRI is a marker of endometriosis

STUDY QUESTION

Could the anogenital distance (AGD) as assessed by MRI (MRI-AGD) be a diagnostic tool for endometriosis?

SUMMARY ANSWER

A short MRI-AGD is a strong diagnostic marker of endometriosis.

WHAT IS KNOWN ALREADY

A short clinically assessed AGD (C-AGD) is associated with the presence of endometriosis.

STUDY DESIGN SIZE DURATION

This study is a re-analysis of previously published data from a case-control study.

PARTICIPANTS/MATERIALS SETTING METHODS

Women undergoing pelvic surgery from January 2018 to June 2019 and who had a preoperative pelvic MRI were included. C-AGD was measured at the beginning of the surgery by a different operator who was unaware of the endometriosis status. MRI-AGD was measured retrospectively by a senior radiologist who was blinded to the final diagnosis. Two measurements were made: from the posterior wall of the clitoris to the anterior edge of the anal canal (MRI-AGD-AC), and from the posterior wall of the vagina to the anterior edge of the anal canal (MRI-AGD-AF).

MAIN RESULTS AND THE ROLE OF CHANCE

The study compared MRI-AGD of 67 women with endometriosis to 31 without endometriosis (controls). Average MRI-AGD-AF measurements were 13.3 mm (±3.9) and 21.2 mm (±5.4) in the endometriosis and non-endometriosis groups, respectively (P < 10-5). Average MRI-AGD-AC measurements were 40.4 mm (±7.3) and 51.1 mm (±8.6) for the endometriosis and non-endometriosis groups, respectively (P < 10-5). There was no difference of MRI-AGD in women with and without endometrioma (P = 0.21), or digestive involvement (P = 0.26). Moreover, MRI-AGD values were independent of the revised score of the American Society of Reproductive Medicine and the Enzian score. The diagnosis of endometriosis was negatively associated with both the MRI-AGD-AF (β = -7.79, 95% CI (-9.88; -5.71), P < 0.001) and MRI-AGD-AC (β = -9.51 mm, 95% CI (-12.7; 6.24), P < 0.001) in multivariable analysis. Age (β = +0.31 mm, 95% CI (0.09; 0.53), P = 0.006) and BMI (β = +0.44 mm, 95% CI (0.17; 0.72), P = 0.001) were positively associated with the MRI-AGD-AC measurements in multivariable analysis. MRI-AGD-AF had an AUC of 0.869 (95% CI (0.79; 0.95)) and outperformed C-AGD. Using an optimal cut-off of 20 mm for MRI-AGD-AF, a sensitivity of 97.01% and a specificity of 70.97% were noted.

LIMITATIONS REASONS FOR CAUTION

This was a retrospective analysis and no adolescents had been included.

WIDER IMPLICATIONS OF THE FINDINGS

This study is consistent with previous works associating a short C-AGD with endometriosis and the absence of correlation with the disease phenotype. MRI-AGD is more accurate than C-AGD in this setting and could be evaluated in the MRI examination of patients with suspected endometriosis.

STUDY FUNDING/COMPETING INTERESTS

N/A.

TRIAL REGISTRATION NUMBER

The protocol was approved by the 'Groupe Nantais d'Ethique dans le Domaine de la Santé' and registered under reference 02651077.

Prognosis of HER2-positive pregnancy-associated breast cancer: Analysis from the French CALG (Cancer Associé à La Grossesse) network

INTRODUCTION

The prevalence of pregnancy-associated breast cancer is increasing. HER2-positive breast cancers typically have a poor prognosis. The objective of our study was to compare the prognosis of patients with HER2-positive breast cancer diagnosed during pregnancy (HER2-positive BCP) to young women diagnosed with HER2-positive breast cancer outside of pregnancy (HER2 non-BCP).

METHODS

Data of patients managed for invasive breast carcinoma between January 2005 and 2020 were retrospectively collected from the database of Tenon University Hospital (Paris, France), part of the "Cancer lié à la Grossesse" network.

RESULTS

Fifty-one patients with HER2-positive BCP were matched on age at diagnosis with 51 HER2-positive non-BCP patients. Locally advanced disease with axillary lymph node involvement were frequent. Tumors were frequently aggressive with high grade (p = 0.57) and high Ki67 (p = 0.15). Among the HER2-positive BCP patients, the mean term at diagnosis was 19.3 week of gestation (WG). Eighty-four percent of the patients continued their pregnancy with a mean term at delivery of 34.2WG. Chemotherapy modalities differed between the two groups: neoadjuvant chemotherapy was more frequent in the HER2-positive BCP group (p = 0.03) and adjuvant chemotherapy more frequent in the HER2 non-BCP group (p = 0.009). The recurrence rate was 10% (n = 5) and 18% (n = 9) in the HER2-positive BCP and HER2 non-BCP groups, respectively, p = 0.25. Breast cancer-free survival was poorer in the HER2-positive BCP group with earlier recurrence, p = 0.008. No difference in type of recurrence was found between the groups (p = 0.58).

CONCLUSION

This matched case-control study implies that patients with HER2-positive BCP still have a poorer prognosis than non-pregnant HER-positive patients.

Use of the EFI score in endometriosis-associated infertility: A cost-effectiveness study

BACKGROUND

The management of endometriosis-related infertility is still under debate. The Endometriosis Fertility Index (EFI) score is performant to predict the occurrence of a spontaneous pregnancy following surgery, but was not evaluated in a cost-effectiveness perspective. Our objective was to quantify fertility outcomes, and costs of different care pathways for endometriosis-associated infertility after primary surgery, with a stratification on the EFI score.

STUDY DESIGN

We conducted a cost-effectiveness analysis based on a decision-tree model in a Tertiary-care university hospital. Extracted form a prospectively maintained database, 608 patients with endometriosis-associated infertility, who underwent laparoscopic treatment with an evaluation of the EFI score, were discriminated between different strategies: natural conception, immediate IVF-ICSI, delayed IVF-ICSI. The pregnancy rate and the live birth rate were the effectiveness outcomes. We considered direct and indirect costs in each strategies. The analysis was stratified according to the EFI score.

RESULTS

After surgery, 163 women with immediate IVF-ICSI (strategy I) were compared with 445 women who had natural conception attempts during a year (strategy II). After a year failure of natural conception attempts, 133 women continuing natural conception attempts (strategy III) were compared with 168 women who had delayed IVF-ICSI (strategy IV). The respective PR and LBR were 62.6 % and 52.1 % for strategy I, and 32.4 % and 23.8 % for strategy II. Compared to strategy II, strategy I was more costly and more effective (Incremental Cost Effectiveness Ratio (ICER): 31,469 €/pregnancy and 33,568 €/live birth)). No added benefit was observed for patients in strategy I with an EFI score [0-3] after two IVF-ICSI cycles. Strategy III was strongly dominant versus strategy IV for patients with an EFI score [9-10]. Compared to strategy III, strategy VI was more costly and more effective (ICER: 79,674 €/pregnancy, 53,188 €/pregnancy and 27,748 €/pregnancy respectively for patients with an EFI score [7-8], [4-6] and [0-3]).

CONCLUSION

Immediate IVF-ICSI after surgery is effective but associated with substantial costs for the healthcare system. Taking into account healthcare costs, the EFI is a useful score for helping a couple decide between different care pathways -natural conception, immediate or delayed IVF-ICSI- after surgery for endometriosis-associated infertility.

Comparison of robotic versus conventional laparoscopy for the treatment of colorectal endometriosis: Pilot study of an expert center

INTRODUCTION

Surgical management of deep endometriosis with colorectal involvement remains an option after failure of medical treatments. Conventional laparoscopy is currently considered the standard approach for surgical treatment. Recently, assisted-robotic laparoscopy emerged as an alternative to conventional laparoscopy but with low evidence.

METHODS

From March 2019 to September 2019, we conducted a prospective cohort study of 48 patients undergoing a surgical treatment for colorectal endometriosis (rectal shaving, discoid excision or segmental resection). The interventions were either performed by robotic or conventional laparoscopy. Patients' characteristics, operative and post-operative data were compared between the robotic and the conventional laparoscopic group.

RESULTS

48 patients were included, 25 in the conventional laparoscopy group and 23 in the robotic group. Patients' characteristics and operative findings were similar between the two groups, except for a trend in a higher incidence of associated surgical urinary or digestive procedures in the robotic group (p = 0.06). The mean total surgical room occupancy time and operating time were longer in the in the robotic group (281 ± 97 min vs 208 ± 85 min; p = 0.008) and (221 ± 94 min vs 163 ± 83 min (p = 0.03), respectively. The mean intra operative blood loss, the incidence of intra operative, post-operative complication (according to Clavien-Dindo classification) rates and voiding dysfunction were similar in the two groups. The rate of grade III complication was higher in the robotic group (13 % vs 0%) without reaching a significance (p = 0.17). The mean hospital stay was 8 ± 4.4 days in the robotic group and 6.5 ± 2.6 days in the conventional laparoscopy group (p = 0.18).

CONCLUSION

Despite our initial experience in robotic surgery, our results support that robotic surgery is an adequate alternative to conventional laparoscopy for endometriosis colorectal resection.

Cost and outcomes of the ultrasound screening program for birth defects over time: a population-based study in France

OBJECTIVE

To assess trends in the average costs and effectiveness of the French ultrasound screening programme for birth defects.

DESIGN

A population-based study.

SETTING

National Public Health Insurance claim database.

PARTICIPANTS

All pregnant women in the 'Echantillon Généraliste des Bénéficiaires', a permanent representative sample of 1/97 of the individuals covered by the French Health Insurance System.

MAIN OUTCOMES MEASURES

Trends in the costs and in the average cost-effectiveness ratio (ACER) of the screening programme (in € per case detected antenatally), per year, between 2006 and 2014. incremental cost-effectiveness ratio (ICER) from 1 year to another were also estimated. We assessed costs related to the ultrasound screening programme of birth defects excluding the specific screening of Down's syndrome. The outcome for effectiveness was the prenatal detection rate of birth defects, assessed in a previous study. Linear and logistic regressions were used to analyse time trends.

RESULTS

During the study period, there was a slight decrease in prenatal detection rates (from 58.2% in 2006 to 55.2% in 2014; p=0.015). The cost of ultrasound screening increased from €168 in 2006 to €258 per pregnancy in 2014 (p=0.001). We found a 61% increase in the ACER for ultrasound screening during the study period. ACERs increased from €9050 per case detected in 2006 to €14 580 per case detected in 2014 (p=0.001). ICERs had an erratic pattern, with a strong tendency to show that any increment in the cost of screening was highly cost ineffective.

CONCLUSION

Even if the increase in costs may be partly justified, we observed a diminishing returns for costs associated with the prenatal ultrasound screening of birth defects, in France, between 2006 and 2014.

Back to the Future: Schauta-Amreich Radical Vaginal Hysterectomy Assisted by Laparoscopy with Sentinel Lymph Node Biopsy for Early-stage Cervical Cancer

The popularity of laparoscopy to perform radical hysterectomy has massively increased over the last 2 decades. However, oncologic outcomes (overall and disease-free survival) have been found to be better in patients managed by laparotomy compared with laparoscopy, challenging this surgical route. Compared with laparotomy, vaginal access reduces postoperative morbidity, while avoiding potential cancer spread associated with laparoscopy. We describe the procedure of Schauta-Amreich radical vaginal hysterectomy with bilateral salpingo-oophorectomy, assisted laparoscopically, and associated with pelvic sentinel lymph node procedure in a 56-year-old woman with an International Federation of Gynecology and Obstetrics stage IB2 cervical epidermoid carcinoma. A sentinel lymph node procedure was first performed by laparoscopy. Radical hysterectomy was prepared through laparoscopy by dividing the infundibulopelvic, round, and broad ligaments. The procedure was continued by the vaginal route using the Schuchardt incision. We describe each step of the procedure and provide a video. Histology showed a margin-free resection in both the vagina and parametrium with negative sentinel lymph nodes. This description of the Schauta-Amreich radical vaginal hysterectomy technique with a video file could support the teaching of a procedure that may gain in popularity.

Anogenital distance in adult women is a strong marker of endometriosis: results of a prospective study with laparoscopic and histological findings

STUDY QUESTION

Could anogenital distance (AGD) be a non-invasive marker of endometriosis and correlated to the American Society for Reproductive Medicine revised score (r-ASRM) and ENZIAN classifications?

SUMMARY ANSWER

Surgically and histologically proven endometriosis is associated with a short AGD in women of reproductive age but not correlated either to the severity or to the location of the disease.

WHAT IS KNOWN ALREADY

AGD is a marker of intrauterine androgen exposure and exposure to oestrogen-like chemicals such as phthalates. Moreover, exposure to endocrine disruptors, such as organochlorine chemicals, is associated with endometriosis. It has been suggested that a short AGD in women is associated with an increased risk of endometriosis based on clinical and ultrasound exams.

STUDY DESIGN, SIZE, DURATION

A prospective cohort study was conducted from January 2018 to June 2019 in a tertiary-care centre including 168 adult women undergoing pelvic surgery.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Of the 168 women included, 98 patients had endometriosis (endometriosis group) and 70 did not (non-endometriosis group). An operator (not the surgeon) measured the distance from the clitoral surface to the anus (AGD-AC) and from the posterior fourchette to the anus (AGD-AF) before surgery using a millimetre accuracy ruler. Endometriosis was diagnosed on exploration of the abdominopelvic cavity, and the r-ASRM and ENZIAN scores were calculated. All removed tissues underwent pathological examination.

MAIN RESULTS AND THE ROLE OF CHANCE

Mean (±SD) AGD-AF measurements were 21.5 mm (±6.4) and 32.3 mm (±8.1), and average AGD-AC measurements were 100.9 mm (±20.6) and 83.8 mm (±12.9) in the endometriosis and non-endometriosis groups (P < 0.001), respectively. Mean AGD-AF and AGD-AC measurements were not related to r-ASRM stage (P = 0.73 and 0.80, respectively) or ENZIAN score (P = 0.62 and 0.21, respectively). AGD-AF had a better predictive value than AGD-AC for discriminating the presence of endometriosis (AUC = 0.840 (95% CI 0.782–0.898) and 0.756 (95% CI 0.684–0.828)), respectively. For AGD-AF, an optimal cut-off of 20 mm had a specificity of 0.986 (95% CI 0.923–0.999), sensitivity of 0.306 (95% CI 26.1–31.6) and positive predictive value of 0.969 (95% CI 0.826–0.998). In multivariable analysis, the diagnosis of endometriosis was the only variable independently associated with the AGD-AF (β = −9.66 mm 95% CI −12.20–−7.12), P < 0.001).

LIMITATIONS, REASONS FOR CAUTION

The sample size was relatively small with a high proportion of patients with colorectal endometriosis reflecting the activity of an expert centre. Furthermore, we did not include adolescents and the AGD-AF measurement could be particularly relevant in this population.

WIDER IMPLICATIONS OF THE FINDINGS

The measurement of AGD could be a useful non-invasive tool to predict endometriosis. This could be especially relevant for adolescents and virgin women to avoid diagnostic laparoscopy and empiric treatment.

STUDY FUNDING/COMPETING INTEREST(S)

None.

Outcomes of fertility preservation in women with endometriosis: comparison of progestin-primed ovarian stimulation versus antagonist protocols

BACKGROUND

PPOS protocols, initially described for FP in women with cancer, have many advantages compared to antagonist protocols. PPOS protocols were not evaluated for women with endometriosis. The objective of the study was to describe fertility preservation outcomes in women with endometriosis and to compare an antagonist protocol with a Progestin-Primed Ovarian Stimulation (PPOS) protocol.

METHOD

We conducted a prospective cohort study associated with a cost-effectiveness analysis in a tertiary-care university hospital. The measured outcomes included the numbers of retrieved and vitrified oocytes, and direct medical costs. In the whole population, unique and multiple linear regressions analysis were performed to search for a correlation between individual characteristics and the number of retrieved oocyte.

RESULTS

We included 108 women with endometriosis who had a single stimulation cycle performed with either an antagonist or a PPOS protocol. Overall, 8.1 ± 6.6 oocytes were retrieved and 6.4 ± 5.6 oocytes vitrified per patient. In the multiple regression model, age (p = 0.001), prior ovarian surgery (p = 0.035), and anti-Mullerian hormone level (p = 0.001) were associated with the number of retrieved oocytes. Fifty-four women were stimulated with an antagonist protocol, and 54 with a PPOS protocol. A mean of 7.9 ± 7.4 oocytes were retrieved in the antagonist group and 8.2 ± 5.6 in the PPOS group (p = 0.78). A mean of 6.4 ± 6.4 oocytes were vitrified in the antagonist group and 6.4 ± 4.7 in the PPOS group (p = 1). In the cost-effectiveness analysis, the PPOS protocol was strongly dominant over the antagonist protocol.

CONCLUSION

Fertility preservation procedures are feasible and effective for patients affected by endometriosis. Antagonist and PPOS protocols were associated with similar results but the medico-economic analysis was in favor of PPOS protocols.

Trends in resource use and effectiveness of ultrasound detection of fetal structural anomalies in France: a multiple registry-based study

OBJECTIVE

To analyse trends in the number of ultrasound examinations in relation to the effectiveness of prenatal detection of birth defects using population-based data in France.

DESIGN

A multiple registry-based study of time trends in resource use (number of ultrasounds) and effectiveness (proportion of cases prenatally diagnosed).

SETTING

Three registries of congenital anomalies and claims data on ultrasounds for all pregnant women in France.

PARTICIPANTS

There were two samples of pregnant women. Effectiveness was assessed using data from three French birth defect registries. Resource use for ultrasound screening was based on the French national healthcare database.

MAIN OUTCOME MEASURES

The main outcome measures were prenatal diagnosis (effectiveness) and the average number of ultrasounds (resource use). Statistical analyses included linear and logistic regression models to assess trends in resource use and effectiveness of prenatal testing, respectively.

RESULTS

The average number of ultrasound examinations per pregnancy significantly increased over the study period, from 2.47 in 2006 to 2.98 in 2014 (p=0.005). However, there was no significant increase in the odds of prenatal diagnosis. The probability of prenatal diagnosis was substantially higher for cases associated with a chromosomal anomaly (91.2%) than those without (51.8%). However, there was no evidence of an increase in prenatal detection of either over time.

CONCLUSIONS

The average number of ultrasound examinations per pregnancy increased over time, whereas the probability of prenatal diagnosis of congenital anomalies did not. Hence, there is a need to implement policies such as high-quality training programmes which can improve the efficiency of ultrasound examinations for prenatal detection of congenital anomalies.

[Ultrasound screening for birth defects: A medico-economic review]

OBJECTIVES

The systematic use of ultrasound during pregnancy aims at birth defect detection. Our objective was to assess the economic efficiency of prenatal ultrasound screening for fetal malformations.

METHODS

We carried out a literature review on Medline via PubMed between 1985 and 2015, from the economic perspective of the prenatal ultrasound screening for fetal malformations.

RESULTS

The literature on this subject was sparse and we selected only twelve articles presenting relevant economic data, of which only eight were proper medico-economic studies. We found arguments for the economic effectiveness of ultrasound screening for fetal malformation detection, which is largely linked to the terminations of pregnancies and to the cost of the handicaps "avoided". However, none of the reviewed articles could reach medico-economic conclusions. Additionally, we highlighted various elements making economic analyses more complex in this field: the choice of the method, the uncertainty around two essential parameters (the efficiency of ultrasound and the costs of procedures) and the difficulties to compare or to generalize results. We also noticed important methodological heterogeneity among the studies and the absence of French study.

CONCLUSIONS

Previously published data are insufficient to assess the economic efficiency of prenatal ultrasound screening for fetal malformations.

Liver function and plasma antioxidant status in intensive care unit patients requiring total parenteral nutrition: comparison of 2 fat emulsions

BACKGROUND

Efficacy and safety of an alpha-tocopherol-enriched emulsion incorporating soybean, coconut, olive, and fish oils (SMOF) are compared in terms of biologic parameters to those of soybean oil-based emulsion (LIPOVEN).

METHODS

Twenty stressed patients were randomly assigned in a double-blind study to receive at least a 5-day course of total parenteral nutrition. Plasma activities of liver enzymes, C-reactive protein, antioxidant capacity, alpha-tocopherol, retinol, and low density lipoprotein (LDL)-alpha-tocopherol levels were determined. LDL-lipid oxidation is measured after incubation of the LDL in the presence of a prooxidant.

RESULTS

The plasma activities of liver enzymes and the phospholipids/apo A1 ratio were increased in both groups. However, in the SMOF group the increases were lower than in the LIPOVEN group and non-significant for the CRP plasma level and the alanineamino-transferase activity. Before parenteral nutrition, the plasma antioxidant status was markedly reduced in both groups. After parenteral nutrition discontinuation, the antioxidant capacity and the amount of LDL-derived oxidation by-products formed were comparable in both groups. There was a significant improvement in plasma lipophilic antioxidant vitamins and LDL-alpha-tocopherol levels only in the SMOF group.

CONCLUSIONS

The lower increase of plasma liver enzymes and phospholipids/apo A1 ratio in the SMOF group suggest a better liver function than in the LIPOVEN group. This beneficial effect results in a higher liver mobilization and plasma levels of lipophilic antioxidants. They could, together with higher delivery of omega-3 fatty acids to peripheral tissues, contribute positively to survival rate of stressed patients.

Prefrontal cortex lesions and MAO-A modulate aggression in penetrating traumatic brain injury

OBJECTIVE

This study investigates the interaction between brain lesion location and monoamine oxidase A (MAO-A) in the genesis of aggression in patients with penetrating traumatic brain injury (PTBI).

METHODS

We enrolled 155 patients with PTBI and 42 controls drawn from the Vietnam Head Injury Study registry. Patients with PTBI were divided according to lesion localization (prefrontal cortex [PFC] vs non-PFC) and were genotyped for the MAO-A polymorphism linked to low and high transcriptional activity. Aggression was assessed with the aggression/agitation subscale of the Neuropsychiatric Inventory (NPI-a).

RESULTS

Patients with the highest levels of aggression preferentially presented lesions in PFC territories. A significant interaction between MAO-A transcriptional activity and lesion localization on aggression was revealed. In the control group, carriers of the low-activity allele demonstrated higher aggression than high-activity allele carriers. In the PFC lesion group, no significant differences in aggression were observed between carriers of the 2 MAO-A alleles, whereas in the non-PFC lesion group higher aggression was observed in the high-activity allele than in the low-activity allele carriers. Higher NPI-a scores were linked to more severe childhood psychological traumatic experiences and posttraumatic stress disorder symptomatology in the control and non-PFC lesion groups but not in the PFC lesion group.

CONCLUSIONS

Lesion location and MAO-A genotype interact in mediating aggression in PTBI. Importantly, PFC integrity is necessary for modulation of aggressive behaviors by genetic susceptibilities and traumatic experiences. Potentially, lesion localization and MAO-A genotype data could be combined to develop risk-stratification algorithms and individualized treatments for aggression in PTBI.

[Comparison of mortality according to the revascularisation strategies and the symptom-to-management delay in ST-segment elevation myocardial infarction]

The aim of this study was to compare the mortality associated to primary angioplasty and thrombolysis in patients managed for an elevated ST-segment acute coronary syndrome in less than or more than 3 hours after the onset of symptoms. We analyzed the in-hospital mortality of 846 patients (including 276 [33%] treated by primary angioplasty, 511 [60%] by thrombolysis, and 59 [7%] without revascularisation) included from October 2002 to December 2003 in a registry of patients with an elevated ST-segment acute coronary syndrome managed in less than 12 hours in Northern Alps districts. The overall in-hospital mortality was at 6.0% (51/846). For the 631 managed in <3 hours, the mortality rates were respectively at 5.0%, 4.6% and 11.1% respectively in case of primary angioplasty, thrombolysis and without revascularisation (p=0.21). For the 215 patients with pain lasting more than 3 hours, the mortality rates were at 2.7%, 10.3% and 21.7% in case of primary angioplasty, thrombolysis and no revascularisation, respectively (p=0.01). In the multivariable analysis, the OR of death in case of thrombolysis compared to primary angioplasty was at 1.65 (95% IC: 0.73 - 3.75) for patients with pain " 3 hours, and 4.98 (95% IC: 1.32-18.37) for those with pain > 3 hours. These results are in line with randomized trials conclusions and confirm the international guidelines suggesting primary angioplasty for patients with a chest pain >3 hours and either angioplasty or thrombolysis in case of chest pain < 3 hours.

Surgical management of renal cell carcinoma during the second trimester of pregnancy

Renal cell carcinoma is rarely diagnosed during pregnancy and its management represents a real challenge. Pregnancy demands special consideration in terms of diagnostic evaluation and management, particularly during the second trimester. We report a patient undergoing left radical nephrectomy using a thoracoretroperitoneal approach at 22 weeks' gestation. Histological analysis revealed a pT2R0G2 chromophobic renal cell carcinoma. Furthermore, we review the sparse literature available.

[Carbonic anhydrase inhibitors and calcium phosphate stones]

We report a case of a 33 years old female with a history of paroxystic hemidystonia treated by acetazolamide, a carbonic anhydrase inhibitor (CAI), and who developed two years after the initiation of this treatment bilateral radio-opaque stones. Laboratory tests revealed a hyperchloremic acidosis, an elevated urinary pH, a hypercalciuria, a severe hypocitraturia and numerous granulations of amorphous carbonated calcium phosphates and brushite crystals on urinary microscopic examination, the whole suggests a diagnosis of acetazolamide-induced nephrolithiasis. We discuss in this article the lithogenetic process and the usual composition of the stones induced by CAI, and specific risk factors for developing drug-induced lithiasis which should be taken into consideration when prescribing long-term drug regimens.

Home assessment and care

OBJECTIVE

To describe the scope of home care and to give practical advice for incorporating home visits into family practice.

QUALITY OF EVIDENCE

Most of the literature is based on expert opinion, but there are some randomized trials and well done surveys.

MAIN MESSAGE

Although physicians make fewer housecalls than they used to, home visiting is essential to providing good care to certain patients. An approach to evaluating patients and their home environments is presented. Management plans should be formulated in collaboration with home care teams. We offer practical advice for incorporating home visits into practice.

CONCLUSION

Home visits can be a valuable and rewarding complement to family practice and are essential for the development of home care.

[Hypertensive disorders in pregnancy]

Hypertension in pregnancy is defined by a systolic blood pressure > or = 140 mm Hg and a diastolic blood pressure of > or = 90 mm Hg or by a rise in blood pressure of systolic > or = 30 mm Hg and diastolic > or = 15 mm Hg. High blood pressures are found in 5-10% of all pregnancies. The outcome of pregnancy is influenced by the fact whether there occurs a proteinuria in addition to hypertension. While the prognosis of an isolated hypotension is good, the combination of hypertension and proteinuria leading to preeclampsia is the primary cause of maternal death in many countries and is responsible for 20-25% of perinatal mortality. A simple classification divides between chronic hypertension, preeclampsia, preeclampsia superimposed on chronic hypertension and transient hypertension. With chronic hypertension pregnancy outcome is determined by a preexisting nephropathy and the occurrence of a superimposed preeclampsia. Preeclampsia and superimposed preeclampsia are pregnancy induced multiorganic diseases, endangering both the mother and the fetus. Transient hypertension is a benign pathology, which occurs toward the end of pregnancy usually on the basis of a latent essential hypertension, which is laid open through pregnancy. While a severe chronic hypertension in pregnancy must be treated to prevent a hypertensive maternal encephalopathy, a less severe chronic hypertension should not be treated as the risk of a superimposed preeclampsia and the maternal and fetal outcome cannot be influenced by antihypertensive therapy. The incidence of preeclampsia is 3-5% in nulliparae and 0.5% in multiparae. Preeclampsia is a severe and dangerous pathology with an unknown etiology. Pregnancy termination is the only causal therapy. At present it is still recommended to terminate a severe preeclampsia after stabilizing the mother, irrespective of gestational age. In less severe preeclampsia occurring before 32 weeks of gestation, termination of pregnancy can be postponed under intensive monitoring and a prophylaxis with magnesium sulfate in order to accelerate the fetal lung maturation with glucocorticoids. A conservative management in the case of a HELLP-syndrome (Haemolyis, Elevated Liver enzymes, Low Platelets), which is a very severe form of preeclampsia, is not recommended because it hasn't been validated in prospective controlled studies. The most dangerous complication of preeclampsia is eclampsia, which is defined by general tonic-clonic convulsions before or after birth. The most effective prophylaxis of eclamptic attacks is the intravenous therapy with magnesium sulfate. A primary prohylaxis for preeclampsia doesn't exist. Treatment with low-dose aspirin in high-risk patients, i.e. after a severe preeclampsia, in cases of chronic hypertension, in cases of nephropathy and in cases with antiphospholipid-syndrome++ can be recommended. The prophylactic use of low-dose heparin, which has lead to a significant decreased incidence of preeclampsia in retrospective analysis, is now the object of a randomized, controlled trial in our hospital. All women who suffered from a preeclampsia should have a check-up after 3-6 months. Preexisting pathologies are found in up to 40% of patients, mostly in multiparae, i.e. chronic hypertension, nephropathy, endocrine pathologies, anomalies of blood coagulation and antiphospolipid-syndrome.

Prevention of preeclampsia with heparin and antiplatelet drugs in women with renal disease

In a retrospective cohort study of women with renal disease in pregnancy we investigated if: 1. low dose aspirin reduced the prevalence of preeclampsia and improved fetal outcome compared to no anticoagulant therapy. 2. heparin plus low dose aspirin and/or dipyridamole reduced the prevalence of preeclampsia and improved fetal outcome compared to i. no treatment ii. low dose aspirin alone. Women with renal disease were allocated into 3 groups according to the treatment received during their pregnancies: I. no prophylactic heparin or antiplatelet drugs, n = 76 II. prophylactic low-dose aspirin 75(50-150)mg, n = 27 III. prophylactic subcutaneous heparin 10,000 (5000-12,500) IU b.d. combined with low-dose aspirin 50 (50-150)mg and/or dipyridamole 400 (200-400)mg, n = 44. Preeclampsia and fetal outcome was analysed according to treatment group. Preeclampsia was less common in the heparin group (2.3%) compared with 27.6% in the no treatment group [O.R. 0.06 (0.01-0.30)] and 25.9% in the aspirin group [O.R. 0.07 (0.01-0.38)]. Women on aspirin, who developed preeclampsia, delivered later in pregnancy [35.4 (33-38.2) weeks] than preeclamptic women on no treatment [29 (22-38) weeks], p = 0.04. There was a trend to reduced perinatal deaths in the heparin + antiplatelet drug group, [2.3%; O.R., 0.17 (0.02-1.4)] and in the aspirin group [0%, O.R., 0.13 (0.01-2.3)] compared with 11.7% perinatal deaths in the no treatment group. Heparin with anti-platelet drugs may prevent preeclampsia in high risk women with renal disease. Further investigation in a randomized trial is indicated.

Central nervous system noradrenergic control of sympathetic outflow in normotensive and hypertensive humans

We applied transmitter washout methodology, sampling internal jugular venous plasma via a percutaneously placed catheter, to study CNS norepinephrine release in humans and its relation to peripheral sympathetic activity. Norepinephrine overflows into the venous drainage of the brain, as do its precursor, DOPA, and metabolites DHPG and MHPG, indicating that the blood-brain barrier provides an incomplete impediment to their outward flux from the brain. Pharmacological testing with two drugs which altered CNS norepinephrine turnover, the tricyclic antidepressant desipramine and the ganglionic blocker, trimethaphan, demonstrated a direct relation existed between CNS norepinephrine release and sympathetic nerve firing rates. In essential hypertension, the sympathetic activation commonly present was associated with, and possibly caused by increased CNS release of norepinephrine, manifested in elevated overflow of norepinephrine, MHPG and DHPG from the brain. Bilateral jugular sampling, coupled with a cerebral venous sinus scan to delineate the drainage pattern, demonstrated that this increased norepinephrine release was confined to subcortical forebrain regions.

Uterine artery waveform as a predictor of pregnancy outcome in women with underlying renal disease

To investigate the use of uterine artery flow velocity waveforms in predicting gestational hypertension (GH), preeclampsia (PE) and intrauterine growth retardation (IUGR), Colour Doppler ultrasound of the uterine arteries was performed at 19-24 weeks gestation in 51 women with known renal disease. On four consecutive waveforms, peak systolic (A), end-diastolic (B) and early diastolic (C) velocities were measured. Resistance index (RI) was calculated as (A-B)/A, and the severity of the waveform notch expressed as the AC ratio (A/C). Gestational hypertension was defined as a blood pressure (BP) > or = 140/90 mmHg with an increase of at least 15 mmHg in diastolic BP. PE included women with gestational hypertension and proteinuria > 300 mg/24 h or a doubling of early gestation protein excretion. IUGR was defined as a birthweight less than the 10th percentile for gestation. RI and/or AC ratio in 14 women (27%) exceeded the 90th percentile for gestational age of our low risk control population. Of the women with an abnormal test, 11 (79%) developed complications, 8 (57%) developed GH or PE, 3 (21%) IUGR alone, 2 (14%) GH and IUGR, and in one women intrauterine fetal death of an IUGR infant occurred, and 3 (21%) had an uncomplicated pregnancy. Of the women with a normal test, 34 (92%) had an uncomplicated pregnancy, and only 3 (8%) developed GH or IUGR. In summary, uterine artery waveform indices at 19-24 weeks gestation may be useful for the prediction of pregnancy complications in woman with underlying renal disease.

Uterine artery Doppler flow velocity waveforms in the second trimester for the prediction of preeclampsia and fetal growth retardation

OBJECTIVE

To determine the optimal method of measuring uterine artery waveforms with Doppler ultrasound when screening healthy nulliparas for subsequent development of preeclampsia and fetal growth retardation (FGR).

METHODS

Color Doppler ultrasound was used to obtain uterine artery waveforms at 19-24 weeks' gestation in 458 nulliparas. In each uterine artery, the resistance index (RI), the ratio between peak systolic (A) and early diastolic (C) blood flow velocities (AC ratio) (a measure of the early notch in the uterine artery waveform), and placental position were recorded. The predictive values of these uterine artery Doppler measurements were evaluated for pregnancy complications. The major end points were preeclampsia and small for gestational age (SGA) infants.

RESULTS

The best screening test for preeclampsia and SGA infants was the placental-side uterine artery RI or AC ratio above the 90th percentile for gestational age when the placenta was located on the left or right, and the highest RI or AC ratio when the placenta was midline. This method identified 51% of women with subsequent preeclampsia or SGA infants and had a positive predictive value of 29%. The test detected women with severe disease requiring delivery before 37 weeks with a sensitivity of 83% and specificity of 88%. However, the results were similar if the placental-side uterine artery RI was above an arbitrary cutoff of 0.56 or the AC ratio was above 2.05. A normal test predicted an uncomplicated pregnancy.

CONCLUSIONS

Although abnormal uterine artery Doppler is associated with an increased risk of preeclampsia and FGR, the positive predictive values do not support its introduction as a routine screening test in nulliparous women.

Monoaminergic neuronal activity in subcortical brain regions in essential hypertension

In this study we aimed to elucidate the role of central noradrenergic, dopaminergic, adrenergic and serotonergic neuronal systems in the development of essential hypertension. Fifteen untreated essential hypertensive subjects (aged 44 +/- 3 years) and 32 healthy volunteers (aged 38 +/- 3 years) participated in this study. By combining direct blood sampling techniques with cerebral blood flow scans we were able to differentiate between cortical and subcortical venous drainage of the brain. Veno-arterial MHPG, HVA and 5-HIAA plasma concentration gradients combined with internal jugular vein plasma flows were used, according to the Fick Principle, to derive metabolite spillovers which in turn were used as indicators of central noradrenergic, dopaminergic and serotonergic neuronal activity, respectively. These amine systems, in both the brainstem and forebrain, have been implicated in the regulation of sympathetic outflow and blood pressure. Total body noradrenaline spillover to plasma was concurrently measured to assess the relationship between central monoamine turnover and sympathetic activity. Compared to their healthy counterparts the hypertensive subjects had an elevated release of MHPG from subcortical brain regions (1.4 +/- 0.3 v 0.5 +/- 0.2 nmol/min, p < 0.05). An inverse relationship between blood pressure and subcortical HVA overflow existed, with the HVA overflow being significantly lower in the hypertensives (0.5 +/- 0.2 v 2.1 +/- 0.5 nmol/min, p < 0.05). Subcortical 5-HUAA overflow did not differ between the two groups, and adrenaline spillover from the brain was not detected in either group. Subcortical MHPG overflow was significantly correlated with total body NA spillover to plasma (p < 0.05). These results indicate that reciprocal aberrations in subcortical noradrenaline and dopamine turnover exist in essential hypertension. Although the physiological significance of this remains to be unequivocally elucidated we postulate that elevated subcortical noradrenergic activity, presumably in the forebrain where noradrenergic neurons are pressor, may cause sympathoexcitation and play a role in the development of essential hypertension.

The influence of vitamins and trace element supplements on the stability of the pre-corneal tear film

The tear stability af 60 normal healthy subjects was measured and repeated 10 days later. Using a double-blind protocol, during the interim period 2/3 of the subjects (the treatment groups) took a commercially available daily dietary supplement and the remaining 1/3 acted as controls. The recommended daily dose was applied to the treatment groups. 20 of the treatment group took a daily dietary supplement of a mixture consisting of vitamins (e.g. A, B1, B2, B6, E) and trace elements (e.g. calcium iron, manganese), the other 20 took purely vitamin C tablets. The tear stability of both treated groups increased, however, the multi-vitamin and trace element group demonstrated the more consistent and individually predictable improvement. Within this group, the characteristics of the regression line correlating the initial mean (x) and final mean (y) tear stabilities were, y = 5.94 + 1.02x. The tear stability of the control group individuals did not significantly change.

Evidence for increased noradrenaline release from subcortical brain regions in essential hypertension

OBJECTIVE

To test whether the activation of the sympathetic nervous system that is common in essential hypertension derives from subcortical noradrenergic neuronal excitation.

DESIGN AND METHODS

We performed a radionuclide cerebral venous sinus scan, using technetium-99m, to establish which internal jugular vein predominantly drained the cortical (the major jugular vein) and which the subcortical (minor jugular vein) brain regions. Blood samples were then collected simultaneously from catheters placed percutaneously in the brachial artery or radial artery and high in the internal jugular vein in 11 untreated hypertensive patients and 18 normotensive subjects, for determination of the plasma concentrations of noradrenaline, its precursor dihydroxyphenylalanine (DOPA) and its metabolite dihydroxyphenylglycol (DHPG) to calculate their rates of overflow into the cerebrovascular circulation.

RESULTS

In normotensive subjects blood flow determined by thermodilution was significantly higher in the major than in the minor jugular vein. The noradrenaline spillovers into the major and minor jugular veins calculated during infusions of L-[3H]-7-noradrenaline were similar in healthy subjects. The noradrenaline spillover from subcortical regions into the minor jugular vein was significantly higher in the hypertensives than in the normal subjects, as was the overflow of DHPG. In contrast, cortical noradrenaline and DHPG overflows into the major jugular vein were similar in hypertensive and normotensive subjects. Overflow of DOPA into the minor jugular vein, which derives largely from precursor turnover in dopaminergic neurons, was similar in hypertensive and normotensive subjects. Subcortical noradrenaline spillover correlated with neurochemical indices of sympathetic nervous system activity, with total body noradrenaline spillover (r = 0.56, P < 0.05) in normal and hypertensive subjects combined, and with renal noradrenaline spillover in the six hypertensive patients tested (r = 0.91, P < 0.05).

CONCLUSION

These results suggest that increased subcortical noradrenaline release is a possible cause of peripheral sympathetic activation in essential hypertension.

Laparoscopically assisted subtotal colectomy

A technique for laparoscopic total resection of the colon performed in six patients is reported. The diseased colon was separated from the mesocolon and the greater omentum by electrocoagulation and sharp dissection. The mesenteric vessels were divided using an Endo GIA stapling device (AutoSuture, France). The whole colon was removed after transection of the rectum and extraction through a right minilaparotomy. A primary stapled end-to-side ileorectal anastomosis was performed through the anus under laparoscopic guidance. This technique can be applied to cases involving a variety of benign lesions of the entire bowel or multifocal small malignant colonic neoplasms with a decrease in patient morbidity and shorter inpatient period.

A technique of laparoscopic gastrectomy and Billroth II gastrojejunostomy

This report describes a technique of total intraabdominal laparoscopic gastrectomy using laparoscopic stapling and suturing. The reestablishment of continuity of the upper gastrointestinal tract was performed by gastrojejunostomy (Billroth II) using the Endo GIA stapler. This procedure merits inclusion in the armamentarium of approaches toward surgical treatment of recurrent gastric ulcer.