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Comparison of pregnancy outcomes after bariatric surgery by sleeve gastrectomy versus gastric bypass

Objective

Bariatric surgery has an impact on subsequent pregnancies, in particular an association between gastric bypass and small for gestational age. Knowledge is lacking on whether sleeve gastrectomy is associated with more favorable pregnancy outcomes. This study aimed to compare the impact of sleeve gastrectomy and Roux-en-Y gastric bypass on the incidence of small for gestational age (SGA), and of adverse pregnancy outcomes.

Study design

We conducted a retrospective study in a single reference center, including all patients with a history of sleeve or bypass who delivered between 2004 and 2021 after their first pregnancy following bariatric surgery. We compared the incidence of SGA, intrauterine growth retardation, preterm delivery and adverse maternal outcomes between patients who had sleeve versus bypass.

Results

Of 244 patients, 145 had a sleeve and 99 had a bypass. The proportion of SGA < 10th percentile did not differ between the two groups (38/145 (26.2 %) vs 22/99 (22.22 %), respectively, p = 0.48). Preterm birth < 37 WG was lower in the sleeve group (5/145 (3.45%) vs 12/99 (12.12 %) in the bypass group (p = 0.01), as well as NICU hospitalizations (3 (2.07%) vs 12/99 (12.12%), p < 0.01). There was no difference regarding adverse maternal outcomes such as gestational diabetes and hypertensive complications. The proportion of SGA was not lower in patients with bypass when adjusting for other risk factors (BMI, smoking, geographic origin, diabetes and hypertension) (aOR 0.70; 95%CI 0.01 - 2.85).

Conclusion

sleeve was associated with an incidence of SGA which was as high as after bypass, however the incidence of preterm birth was lower.

Impact of hormonal contraception on endometrial histology in patients with Lynch syndrome, a retrospective pilot study

Hormonal contraception (HC) is a well-recognized protection against endometrial cancer (EC) in the general population. It has not been established if this is also applicable to women with Lynch syndrome (LS), a condition associated with a up to 50% lifetime risk of developing EC. The objective of this study was to evaluate if the use of HC influences the incidence of endometrial hyperplasia and EC in women with LS by comparing the histology of annual endometrial biopsies obtained in patients with LS who are using HC versus non-users. This is a retrospective cohort study conducted with endometrial biopsies obtained in women 30 to 50 years of age with LS. The Pearson Chi-square test was performed to compare the prevalence of cancer and hyperplasia in the HC users and in the non-HC users groups. A total of 164 endometrial biopsies obtained among 75 women were suitable for analysis. Among the 86 biopsies obtained in the non-HC group, 81.4% (70/86) were normal. Two cases of endometrial carcinoma (2.3%) and 6 endometrial hyperplasia without atypia were found (7.0%). Among the 78 biopsies performed in patients using HC, 78.2% (61/78) were normal. Three endometrial hyperplasia without atypia (3.8%) and three cases of EC were diagnosed (3.8%). This study suggests that, in women of 30 to 50 years of age with LS, the use of hormonal contraception does not seem to decrease the occurrence of endometrial hyperplasia/carcinoma on annual endometrial histology.

Idiopathic polyhydramnios and postnatal outcomes of children: The role of exome sequencing

OBJECTIVES

The objective of our study was to evaluate the long-term outcome of children born from a pregnancy complicated by idiopathic polyhydramnios. The secondary objective was to investigate factors associated with adverse outcomes.

METHODS

We conducted a retrospective study in two prenatal diagnosis centers between January 1, 2009 and December 31, 2020. Inclusion criteria were pregnancies with a diagnosis of idiopathic polyhydramnios, defined by a deepest pocket greater than 8 cm, no detectable abnormality at ultrasound and a negative amniotic fluid assessment including karyotype, chromosomal microarray, biochemical assays (electrolytes and digestive enzymes), and viruses (parvovirus B19 and cytomegalovirus). One-year outcomes of these children were collected. The primary endpoint was adverse postnatal outcome, defined by at least one of the following criteria: stillbirth, neonatal death, or serious and incurable condition diagnosed in the first year of life.

RESULTS

Of the 245 women referred for isolated polyhydramnios, 73 were diagnosed with idiopathic polyhydramnios after prenatal investigations. The mean age at follow-up of children was 28 months (95% CI 20-36). An adverse outcome occurred in 25% of cases (18/73), with one stillbirth, two neonatal deaths, and 15 severe conditions diagnosed postnatally, including a rate of monogenic disorders of 8.2% (6/73). Pediatric follow-up was normal for 75% of the children (55/73), including a rate of 9% (5/55) of curable conditions. Repeated amnioreduction was independently associated with an adverse outcome.

CONCLUSION

Pregnant women with polyhydramnios should be informed of the increased risk of 25% of perinatal mortality and serious conditions diagnosed after birth.

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.

[Cytosteatonecrosis after breast reconstruction by fat flap with or without ischemic preconditioning]

INTRODUCTION

Cytosteatonecrosis (CTN) is a frequent postoperative complication after breast autologous reconstruction using DIEP (deep inferior epigastric perforator) flap. CTN radiological diagnostic reveals different types of lesions, as nodes or extended fat necrosis, which become in some cases infected, or pass for tumor recurrence after breast cancer treatment. CTN is caused by intraoperative ischemia of the flap, and no current method can prevent postoperative CTN development after DIEP breast reconstruction. Mechanical ischemic preconditioning, consisting in intraoperative briefs consecutive cycles of ischemia reperfusion using vascular clamp upon the graft pedicle, is used in transplantation surgery. This procedure improves the graft tolerance towards ischemic surgical lesions. The aim of this retrospective observational study was to assess PCIM effects on CTN development after DIEP surgery, comparing CTN occurrence after breast reconstruction using DIEP flap with or without intraoperative PCIM.

MATERIAL AND METHODS

All patients breats reconstructed using DIEP flap between novembre 2020 and may 2022, presenting 6 months postoperative breast echography were retrospectively included. Primary outcome was the ultrasonic existence of CTN, according to the Wagner classification. Clinical data, postoperative outcomes such as infection, hematoma or surgical revision, and length of stay in hospital were also recorded.

RESULTS

Twenty nine patients among which 8 PCIM were included. CTN occurrence rate after PCIM (25%) was quite lower than CTN rate without PCIM (71,4%), although the difference was not significant (P=0,088). Other postoperative complications rates were not significantly different with or without PCIM.

CONCLUSION

PCIM seems to improve CTN occurrence after DIEP breast reconstruction, improving fat flap tolerance to ischemic perioperative lesions. Those preliminary results need to be confirmed with clinical prospective study.

Vulvar biopsy: Punch biopsy or cervical forceps biopsy?

OBJECTIVES

The primary objective of our study is to investigate the rate of non-contributory biopsies between punch biopsy(PB) and cervical forceps biopsy(CFB) for a vulvar lesion seen in consultation. The secondary objective of our study is to evaluate the rate of underestimation of a more severe lesion for patients who have undergone vulvar excision.

MATERIAL AND METHOD

This is a retrospective, descriptive, and comparative study conducted at three centers. The study population consisted of patients who underwent vulvar biopsy between 2017 and 2022 in a gynecological surgery consultation at two French hospitals, as well as a city office. The biopsy techniques used were punch or cervical forceps biopsy. Quantitative variables were analyzed using the Mann-Whitney test, while Pearson's or Fisher's Xi2 tests were used for qualitative variables. The significance level was set at 5%.

RESULTS

We conducted a retrospective study of 179 vulvar biopsies, of which 100 were punch biopsies and 79 were cervical forceps biopsies, from a total of 107 patients. There was no significant difference in the rate of non-contributory biopsies between the PB and CB groups (p = 1). When analyzing the secondary endpoint of our study, which included 68 patients who underwent vulvectomy after vulvar biopsy, we found that 66 patients (97%) had a good correlation between the pathology of the vulvar biopsy and that of the vulvectomy specimen.

CONCLUSION

Vulvar biopsy techniques using punch or cervical forceps appear to have similar diagnostic performance and are associated with comparable and low rates of underestimation of invasive lesions.

Prognostic impact of cytoreductive surgery conducted with primary intent, versus cytoreductive surgery after neoadjuvant chemotherapy, in the management of patients with advanced epithelial ovarian cancers: a multicentre, propensity score-matched study from the FRANCOGYN group

OBJECTIVE

To compare survival and morbidity rates between primary cytoreductive surgery (pCRS) and interval cytoreductive surgery (iCRS) for epithelial ovarian cancer (EOC), using a propensity score.

DESIGN

We conducted a propensity score-matched cohort study, using data from the FRANCOGYN cohort.

SETTING

Retrospective, multicentre study of data from patients followed in 15 French department specialized in the treatment of ovarian cancer.

SAMPLE

Patients included were those with International Federation of Gynaecology and Obstetrics (FIGO) stage III or IV EOC, with peritoneal carcinomatosis, having undergone CRS.

METHODS

The propensity score was designed using pre-therapeutic variables associated with both treatment allocation and overall survival (OS).

MAIN OUTCOME MEASURES

The primary outcome was OS. Secondary outcomes included recurrence-free survival (RFS), quality of CRS and other variables related to surgical morbidity.

RESULTS

A total of 513 patients were included. Among these, 334 could be matched, forming 167 pairs. No difference in OS was found (hazard ratio, HR = 0.8, p = 0.32). There was also no difference in RFS (median = 26 months in both groups) nor in the rate of CRS leaving no macroscopic residual disease (pCRS 85%, iCRS 81.4%, p = 0.76). The rates of gastrointestinal tract resections, stoma, postoperative complications and hospital stay were significantly higher in the pCRS group.

CONCLUSIONS

Analysis of groups of patients made comparable by propensity score matching showed no difference in survival, but lower postoperative morbidity in patients treated with iCRS.

Management and survival of foetuses with trisomy 18 in a French retrospective cohort

OBJECTIVES

The main objective of this study was to evaluate parents' current demands following the announcement of trisomy 18 and maternal risks.

MATERIAL AND METHODS

A single-centre retrospective study was performed in the Paris Saclay Foetal Medicine Department from 2018 to 2021. All patients followed up in the department who had cytogenetic confirmation of trisomy 18 were included.

RESULTS

89 patients were recruited. The most common malformations at ultrasound examination were cardiac or brain abnormalities, distal arthrogryposis as well as severe intrauterine growth retardation. 29% of foetuses with trisomy 18 had more than three malformations. 77.5% of patients requested medical termination of pregnancy. Among the 19 patients who chose to continue their pregnancy, 10 (52.6%) presented with obstetrical complications, of which 7 (41.2%) experienced stillbirth; five babies were born alive with no survival at 6 months.

CONCLUSION

In France, in the case of foetal trisomy 18, most women request termination of pregnancy. In the post-natal period, the management of a newborn with trisomy 18 is oriented towards palliative care. The mother's risk of obstetrical complications should be part of counselling. Follow-up, support and safety should be the goal of management of these patients, regardless of the patient's choice.

[Assessment of neuropathic pain among women with suspected endometriosis based on two specific surveys]

OBJECTIVES

A significant proportion of women with suspected endometriosis present neuropathic pain. The aim of this study is to assess this prevalence and the relevance of specific tests used.

METHODS

This is a single-center retrospective study in the CHI of Poissy Saint Germain en Laye with patients who were referred for suspected endometriosis and who benefited from evaluation of neuropathic pain by two distinct questionnaires. The PAINdetect was evaluated by a series of 7 questions scored from 0 to 5 with a positive test if score>18. For the DN4, 7 binary questions were asked and 3 other questions were related to the clinical examination with a positivity threshold reached if score≥4 and in the absence of clinical examination if score≥3.

RESULTS

From November 2020 to June 2022, 57 patients were examined with a prevalence of neuropathic pain (one of the two test positive) evaluated at 36.8%. PAINdetect and DN4 positivity rates were at 26.8% and 30.9%. A discordance was found in 14.8% of cases with a kappa coefficient calculated at 0.63. There was a significant association between radiological examination and neuropathic pain with more neuropathic pain when the radiological examination was negative (P=0.03). The myofascial syndrome was present in only 59.5% of the patients and wasn't associated with neuropathic pain (P=1.00).

CONCLUSION

Prevalence of neuropathic pain in case of suspected endometriosis appears to be high. This need to be confirmed in a multicenter study with also assessment of the validity of the two diagnostic tests.

[Delays and pathways for patients with endometriosis in France: A multicenter study]

INTRODUCTION

The diagnosis of endometriosis is often difficult to make, generating a median diagnostic delay ranging from 2 to 10.7years. A study of the care pathway of these patients seems essential in order to evaluate the diagnostic delay of endometriosis in France and the factors related to the diagnostic delay.

METHODS

This is a prospective multicenter study, conducted between 2017 and 2019. A questionnaire concerning their care pathway and their feelings about the diagnosis was distributed to all patients consulting for endometriosis. Statistical analyses were performed using the Kruskal-Wallis, Chi² and Student's t tests.

RESULTS

Fifity-seven of the 84 patients (67.8%) who completed the questionnaire were included in the evaluation of diagnostic delays. The total diagnostic delay was 12years (min 0; max 33) and was comparable between all inclusion cities (P=0.68). Regarding the care pathway according to specialties, the diagnosis of endometriosis was made by gynecologists in 81% of patients versus 19% by general practitioners. The time between the onset of symptoms and the first consultation was significantly shorter in favor of the general practitioner (2years versus 4years, P=0.012). 60% of the patients reported that their symptoms were labelled as "normal" by the physicians and 35% of them considered them normal themselves.

CONCLUSION

Our study showed that the delay in diagnosis in France was still very long and that the mechanisms of the delay in management were multifactorial. Awareness raising and training of health care providers remains one of the major areas to be optimized.

A Suggested Modification to FIGO Stage IV Epithelial Ovarian Cancer

International Federation of Gynecology and Obstetrics (FIGO) staging classification for stage IV epithelial ovarian cancer (EOC) separates stages IVA (pleural effusion) and IVB (parenchymal and/or extra-abdominal lymph node metastases). We aimed to evaluate its prognostic impact and to compare survival according to the initial metastatic location. We conducted a multicenter study between 2000 and 2020, including patients with a FIGO stage IV EOC. Primary endpoint was overall survival (OS). The secondary endpoints were progression-free survival (PFS) and recurrence rates. We included 307 patients: 98 (32%) had FIGO stage IVA and 209 (68%) had FIGO stage IVB. The median OS and PFS of stage IVA patients were significantly lower than those of stage IVB patients (31 versus 45 months (p = 0.02) and 18 versus 25 months (p = 0.01), respectively). Recurrence rate was higher in stage IVA than IVB patients (65% versus 47% (p = 0.004)). Initial pleural involvement was a poor prognostic factor with a median OS of 35 months versus 49 months for patients without initial pleural involvement (p = 0.024). Patients with FIGO stage IVA had a worse prognosis than patients with FIGO stage IVB EOC. Pleural involvement appears to be relevant for predicting survival. We suggest a modification of the current FIGO staging classification.