Anatomy, embryology, and imaging of situs ambiguous with polysplenia and left IVC

The situs ambiguous or heterotaxy syndrome is a type of syndrome that involves multiple visceral abnormalities, vascular ones and associated with left isomerism. Malformation of gastroenterologic system includes polysplenia (segmented spleen or multiple splenules), agenesis (partial or complete) of the dorsal pancreas and anomalous of the inferior vena cava implantation. Here, we describe and show the anatomy of a patient with left side inferior vena cava, situs ambiguous (complete common mesentery), polysplenia, and short pancreas. We also discuss about the embryologic process and the implications of these anomalies during gynecologic, digestive, and liver surgeries.

HPV Molecular Genotyping as a Differential Diagnosis Tool in Cervical Cancer Metastasis

BACKGROUND

Differentiating metastatic cervical cancer from another primary tumor can be difficult in patients with a history of cervical cancer and a distant lesion. The use of routine HPV molecular detection and genotyping tests could help in these cases. The objective of this study was to identify if an easy-to-use HPV molecular genotyping assay would allow differentiating between HPV tumor metastasis and a new independent primary non-HPV-induced tumor.

MATERIALS AND METHODS

Between 2010 and 2020, we identified patients with a primary cervical carcinoma who also had another secondary lesion. This identification included a clinical and histologic differential diagnosis of metastatic cervical cancer versus a new primary cancer or metastatic cancer from another site. We used a routine multiplex real-time PCR (rt-PCR) Anyplex^TM II HPV28 (Seegene, Seoul, Republic of Korea) to detect the high-risk (HR)-HPV genome in the distant lesions in these patients.

RESULTS

Eight cases of cervical cancer with a new secondary lesion were identified. In seven, HR-HPV DNA was detected in the biopsy of the distant lesion, which confirmed the diagnosis of cervical cancer metastasis. In the remaining case, no HPV was detected in the secondary lung biopsy, confirming the diagnosis of new primary lung cancer.

CONCLUSION

Our results pave the way for HPV molecular genotyping use in cases of newly diagnosed distant lesions in patients with a history of HPV cervical neoplasia by using a routine diagnosis process to complete the clinical and histologic differential diagnosis when confronted with ambiguous situations.

[Feasibility and security of laparoscopic (± robotic) total hysterectomy in outpatient surgery: A French multicenter retrospective study]

OBJECTIVE

To assess the feasibility and safety of total hysterectomy by laparoscopic approach (± robot assisted) in ambulatory.

MATERIALS AND METHODS

French three-center retrospective study including 165 patients who had laparoscopic (± robot assisted) total hysterectomy scheduled as outpatients from January 2016 to December 2020. Clinical and perioperative data were collected. Factors associated with outpatient failure and rehospitalization were evaluated.

RESULTS

The outpatient success rate was 92.7%. Factors associated with outpatient failure were incision time>13:00, large volume of blood loss, intraoperative complications with Oslo score≥2, uterine weight≥250g, indication for benign pathology, and robot-assisted approach. Among patients managed as outpatients, 7.2% were rehospitalized at a mean of 10 days from surgery. The factors associated with rehospitalization were the use of an effective antiaggregant or anticoagulant treatment and the use of intraoperative adhesiolysis. Four patients (2.6%) underwent revision surgery.

CONCLUSION

Minimally invasive hysterectomy can be performed as an outpatient procedure even in cases of malignant pathology. Age and body mass index are not associated with an increased risk of failure or re-hospitalization within one month.

Perioperative parameters to consider for enhanced recovery in surgery (ERS) in gynecology (excluding breast surgery)

The current review explores the Enhanced Rehabilitation in Surgery (ERS) approach in the specific context of gynecological surgery. Implementation of an ERS protocol in gynecological surgery reduces postoperative complications and length of stay without increasing morbidity. An ERS approach is based on maintaining an adequate diet and hydration before the operation, according to the recommended time frame, to reduce the phenomenon of insulin resistance, and to optimize patient comfort. On the other hand, the use of anxiolytic treatment as premedication is not recommended. Systematic preoperative digestive preparation, a source of patient discomfort, is not associated with an improvement in the postoperative functional outcome or with a reduction in the rate of complications. A minimally invasive surgical approach is preferrable in the context of ERS. Prevention of surgical site infection includes measures such as optimized antibiotic prophylaxis, skin disinfection with alcoholic chlorhexidine, reduction in the use of drainage of the surgical site, and prevention of hypothermia. Early removal of the bladder catheter is associated with a reduction in the risk of urinary tract infection and a reduction in the length of hospital stay. Prevention of postoperative ileus is based on early refeeding, and prevention of postoperative nausea-vomiting in a multimodal strategy to be initiated during the intraoperative period. Intraoperative hydration should be aimed at achieving euvolemia. Pain control is based on a multimodal strategy to spare morphine use and may include locoregional analgesia. Medicines should be administered orally during the postoperative period to hasten the resumption of the patient's autonomy. The prevention of thromboembolic risk is based on a strategy combining drug prophylaxis, when indicated, and mechanical restraint, as well as early mobilization. However, the eclectic nature of the implementation of these measures as reported in the literature renders their interpretation difficult. Furthermore, beyond the application of one of these measures in isolation, the best benefit on the postoperative outcome is achieved by a combination of measures which then constitutes a global strategy allowing the objectives of the ERS to be met.

To what extent is enhanced recovery in surgery used in French obstetrics and gynecology departments?: use of enhanced recovery in gynecologic and obstetric surgery in France

The objective of the present study was to evaluate the implementation of Enhanced Recovery in Surgery (ERS) in French obstetrics and gynecology departments. To achieve this objective, we drafted an online questionnaire about ERS protocols for caesarean sections and hysterectomies with a benign indication and put a hyperlink on the 'French National College of Gynecologists and Obstetricians' (Collège National des Gynécologues et Obstétriciens Français) website. We obtained 112 analyzable responses. Respectively 66% and 34% of the surveyed departments had established ERS protocols for cesarean sections and for hysterectomies with a benign indication. However, not all of the key ERS items were sufficiently implemented: despite the establishment of written protocols, the degree of compliance with the guidelines issued by the French-Speaking Group for Enhanced Recovery After Surgery (Groupement Francophone de Réhabilitation Améliorée Après Chirurgie) was variable. There are few published data on the implementation of ERS in obstetrics and gynecology departments worldwide. In 2010, the Enhanced Recovery After Surgery® Society issued guidelines and a checklist for an ERS protocol. The literature data suggest that for most surgical disciplines, the main ERS criteria are not well known or not widely applied. ERS protocols are still not widespread in French gynecologic surgery departments. Moreover, the application of some of the major ERS items differs markedly from one ERS program to other, which is likely to reduce the level of effectiveness. It therefore appears to be essential to formalize and promote ERS protocols in gynecological surgery.

Surgical training through simulation dedicated to French Ob-gyn residents. Evaluation and satisfaction

OBJECTIVE

In order to be able to develop surgical training of residents through simulation, we carried out a descriptive study, evaluating the satisfaction of participating residents and the benefit of the workshops offered during the 4 th Junior Master Class, free annual training organized in 2017 in Lille University Hospital. It is dedicated to ob-gyn residents in France, overseas departments and territories.

MATERIAL AND METHODS

During two days, plenary sessions and practical workshops on animal models or simulators were organized in laparoscopy, diagnostic and operative hysteroscopy, vaginal surgery and robotic surgery. A questionnaire was given anonymously to each student, collecting on the one hand their surgical curriculum, on the other hand, the evaluations of the theoretical contribution and the quality of the interventions and materials offered during the plenary sessions. The last part was subdivided into a questionnaire specific to each workshop.

RESULTS

The 48 residents who voluntarily followed this training were overwhelmingly satisfied with the quality of the training offered. The practical benefits outweighed the theoretical benefits. These workshops improved their practical skills from 63 % to 84 % depending on the workshops offered. In addition, 100 % of students would recommend this training to other residents and consider it useful for their future practice.

CONCLUSION

These very satisfactory results encourage us to organize new surgical training. Simulation is the key point for an appropriate surgical learning.

[Primary management of endometrial carcinoma. Joint recommendations of the French society of gynecologic oncology (SFOG) and of the French college of obstetricians and gynecologists (CNGOF)]

OBJECTIVES

The management of endometrial carcinoma is constantly evolving. The SFOG and the CNGOF decided to jointly update the previous French recommendations (Institut national du cancer 2011) and to adapt to the French practice the 2015 recommendations elaborated at the time of joint European consensus conference with the participation of the three concerned European societies (ESGO, ESTRO, ESMO).

MATERIAL AND METHODS

A strict methodology was used. A steering committee was put together. A systematic review of the literature since 2011 has been carried out. A first draft of the recommendations has been elaborated, with emphasis on high level of evidence. An external review by users representing all the concerned discipines and all kinds of practice was completed. Three hundred and four comments were sent by 54 reviewers.

RESULTS

The management of endometrial carcinoma requires a precise preoperative workup. A provisional estimate of the final stage is provided. This estimation impact the level of surgical staging. Surgery should use a minimal invasive approach. The final pathology is the key of the decision concerning adjuvant therapy, which involves surveillance, radiation therapy, brachytherapy, or chemotherapy.

CONCLUSION

The management algorithms allow a fast, state of the art based, answer to the clinical questions raised by the management of endometrial cancer. They must be used only in the setting of a multidisciplinary team at all stages of the management.

Economic impact of ulipristal acetate on surgical procedures for uterine fibroids in France

OBJECTIVE

To assess the budget impact of using ulipristal acetate (UPA) 5 mg to treat women with uterine fibroids (UF) causing moderate to severe symptoms.

DESIGN

We modelled trends in the number of surgical procedures for symptomatic UF, with and without the use of UPA for preoperative or intermittent treatment and assessed the budget impact of UPA use from the French national healthcare insurance system perspective.

SETTING

A French national hospital database (PMSI) that records admissions and relative procedures to public and private hospitals.

PARTICIPANTS

Women eligible for surgical procedures for uterine fibroids.

MAIN OUTCOME MEASURES

Economic impact of UPA treatment.

RESULTS

This study based on observational retrospective data shows that the current use of UPA in its preoperative indication was associated with 5645 fewer surgeries from 2013 to 2015. Extrapolation suggests 17 885 fewer surgeries from 2016 to 2019. Overall, preoperative use of UPA results in substantial cost savings for the French national healthcare insurance system, with a cumulated budget impact estimated at €-5 million from 2013 to 2015 and €-13.5 million from 2016 to 2019. In addition, treating women nearing the menopause (≥48 years old) with intermittent treatment from 2017 to 2019 could produce an incremental cost saving of €19 million.

CONCLUSIONS

This study shows that the use of UPA in women eligible for surgical procedures for UF is associated with considerable savings for the French national healthcare insurance system in both preoperative and intermittent indications by decreasing the need to perform surgeries.

Reproducibility of the interpretation of coronal 3D ultrasound view of the uterus to evaluate the position of Essure® 3 months after hysteroscopic procedure

OBJECTIVE

Three-dimensional sonography is a good alternative method to assess the position of microinserts. Adequate position after three months allows for the interruption of other contraception. Objective is to evaluate inter-observer reproducibility of the interpretation of coronal transvaginal 3D ultrasound view of the uterus to evaluate the position of Essure^®.

STUDY DESIGN

Inter-observer reproducibility study. Fifty women underwent successful bilateral placement of microinserts (Essure^®) by hysteroscopy in the Department of Gynaecology of a teaching hospital and were included in the study. At three month, 3D ultrasound coronal views of the fifty uterus (accounting for one hundred microinserts) were assessed by five different observers and microinsert position was classified according to the classification described by Legendre et al. Inter-observer reproducibility in reading the 3D coronal view of the uterus was evaluated.

RESULTS

The k-value was disparate, from 0.26 to 0.82. Inter-observer reproducibility then ranged from fair to almost perfect, depending on a prior knowledge of the position classification.

CONCLUSIONS

Transvaginal 3D coronal view of the uterus is sufficient to assess the positioning of the microinserts when the practionner or the surgeon is familiar with the classification method.

[Analysis from the French DRG-based information system (PMSI) of conservative surgical treatment for abnormal uterine bleeding in 2008-2010]

OBJECTIVE

To evaluate the conservative surgical treatment for abnormal uterine bleeding from the Medicalized Information System Program (PMSI).

MATERIALS AND METHODS

The diagnosis codes were selected from 10th version of the international classification disease. A transversal and longitudinal descriptive analysis was performed from hospital stays, patient's characteristics, medical procedures between 2008-2010.

RESULTS

Nineteen thousand six hundred and seventy-nine patients were admitted in hospital (public or private) for treatment of abnormal uterine bleeding. Endometrial ablation increased by 16,7%, 10.2% for first generation technique (G1) and 63.5% for second generation techniques (G2). G2 were used in 15% of indications. The median age was respectively 45.2±6.4 years old versus 45.8±4.9 years old for G2. The median length of hospital stay was 1.6 ±1with 69% of patients in ambulatory care. The likelihood to have a hysterectomy in the 3 years follow-up was higher after G1 than G2 treatments (P=0.0034) for the patients above 40 years old. In longitudinal study, defined only by endometrial hyperplasia, 11,532 patients were included and only 8.2% had been treated by G2.

CONCLUSION

In spite of the international guidelines since 2008, 85% of patients treated with first generation surgical technique. The failure rate defined by a re-ablation or a hysterectomy is higher after G1. This result must be discussed in relationship with cost effective aspects.

Outcomes and feasibility of laparoscopic sacrocolpopexy among obese versus non-obese women

OBJECTIVE

To compare complication rates and short-term outcomes of laparoscopic sacrocolpopexy among obese and non-obese women.

METHODS

A retrospective multicenter study of 39 obese women and 111 non-obese women was conducted. Obesity was defined as a body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) above 30. Operative parameters (length of operation, associated procedures, complication rate, and length of hospitalization) and short-term (2 months) objective and subjective results were evaluated.

RESULTS

The median BMI in the obese group was 30.5 (interquartile range [IQR] 30-32) versus 23 (IQR 21-25) in the non-obese group (P<0.0001). Short-term anatomic results (postoperative stage of prolapse) were comparable in the obese and non-obese groups: stage 0-1, 87.1% versus 91.6% (P=0.60); stage 2, 10.2% versus 5.5% (P=0.60); stage 3-4, 2.5% versus 2.5% (P=0.60). Complication rates were also similar in the obese and non-obese groups: bladder injury, 2.5% versus 5.4% (P=0.77); laparoconversion, 5.1% versus 4.5% (P=0.77). Rates of reoperation (excluding women with de novo urinary stress incontinence) were 12.8% in the obese group and 8.1% in the non-obese group (P=0.58).

CONCLUSION

Laparoscopic sacrocolpopexy has similar complication rates and short-term outcomes among both obese and non-obese women.

[Uterine torsion in twin pregnancy]

A case of uterine torsion in a 37-years-old woman during twin pregnancy is described. Diagnosis was made during caesarean section and the torsion successfully reduced through a standing laparotomy. Detorsion was accomplished by rotating the uterus to the left. A severe post-partum haemorrhage occurred and hysterectomy was required. The patient recovered and was discharged home with her baby. Uterine torsion at term is a rare obstetric event that occurs mainly in the third trimester with adverse maternal and neonatal consequences and raises several critical management considerations. We review possible diagnostic signs and management of this rare complication from literature.

[Essure implants for tubal sterilisation in France]

OBJECTIVES

Law no. 2001-588 of 4 July 2001 liberalised the practice of tubal sterilisation in France, at the same time as a new hysteroscopic method of female sterilization appeared. The growth of this method has been spurred by the reduced need for analgesia, absence of incision and scar, reduced duration of hospitalization and diminution of costs. The aim of this study was to analyse the use of the Essure procedure in France.

PATIENTS AND METHODS

This multicentre study covered seven French facilities from January 2004 through June 2006. This study included 1061 attempted placements of the Essure micro-insert, marketed by Conceptus SAS (France).

RESULTS

The first placement attempt was successful in 992 cases (94.4%). The success rate for second attempts was 59% (n = 23). Mean VAS was 3,23 +/- 0.19. Ninety-three percent of patients undergoing Essure placement were satisfied or very satisfied.

DISCUSSION AND CONCLUSION

Tubal sterilisation with Essure micro-inserts is a reliable and reproducible method that requires a short period of training. In the future, the hysteroscopic pathway will replace the laparoscopic route.

Les adénocarcinomes du col utérin ont-ils un plus mauvais pronostic que les carcinomes épidermoïdes ?

OBJECTIVE

The objective of this study was to examine the influence of histology on the outcome of patients with cervix carcinoma, treated with radiotherapy and radical surgery.

PATIENTS AND METHODS

Clinical, histological, therapeutical and outcome data of 360 patients with stage IB-II cervix carcinoma patients (45 adenocarcinomas and 315 squamous cell carcinoma) managed between 1985 and 1998 were collected from the database of the Institut Gustave-Roussy.

RESULTS

The incidence of adenocarcinomas slightly increased during the study period (P =0.07). Histological grade was higher for squamous cell carcinoma than for adenocarcinoma (P =0.08). Adenocarcinomas were smaller than squamous cell carcinoma (P =0.06). With only 38% of sterilized hysterectomy specimen vs 52% for squamous cell carcinomas (P =0.07), adenocarcinoma seemed to be less radiosensitive. With a median follow-up of 67 months, histological type did not influence survival.

DISCUSSION AND CONCLUSIONS

Our study demonstrates that radiosensitivity is different between adenocarcinoma and squamous cell carcinoma of the cervix and that surgery may compensate the low radiosensitivity of adenocarcinoma.