Non invasive jacketed telemetry in socially-housed rats for a combined assessment of respiratory system, electrocardiogram and activity using the DECRO system

Respiratory and cardiovascular systems are among the vital organ systems that should be studied in safety pharmacology core battery test. Non-invasive jacketed external telemetry technology that enables concomitant monitoring of both systems has been available and used widely for non-rodent species. Recently, the DECRO system, a miniaturized technology system in line with the "3Rs" principles, has been developed to provide a similar approach in rats. However, data to evaluate this system in socially-housed rats is lacking. Therefore, the objectives of this study were to determine the tolerability and the material integrity of this novel solution in pair-housed rats in two conditions: i) in a single session of 22 h simulating a stand-alone safety pharmacology study design, and ii) in three repeated sessions of 22 h each, simulating the inclusion of safety pharmacology endpoints in a 1-month toxicology study. In both conditions, the GABA_B receptor agonist baclofen was used as a reference compound inducing cardiorespiratory changes. Our results provided evidence that this novel solution was well tolerated, the material was resistant to deterioration and that it allowed the accurate recording, in a non-invasive manner, of cardiorespiratory parameters and activity level in freely moving, pair-housed rats in the above two conditions. In addition, the expected respiratory depressant effects of baclofen were recorded. These results pave the way for considering this novel solution as an enhanced approach for nonclinical safety assessment in rats.

OP0102 DECLINE IN EXCESS RISK OF HEART FAILURE IN PATIENTS WITH RHEUMATOID ARTHRITIS IN RECENT YEARS

Background:

Heart failure (HF) is one of the most common cardiovascular conditions in patients with rheumatoid arthritis (RA). Previous studies showed a 2-fold excess risk of HF in RA versus the general population (1). Whether this has changed over time is not known. Longitudinal studies on trends in occurrence of HF in RA patients over time, and studies comparing trends in HF in RA versus the general population are lacking.

Objectives:

1) To assess trends in incidence of HF in patients with incident RA in 1980-2009; and 2) To compare incidence of HF in RA patients and population-based comparators without RA with RA incidence/ index date in 1980-2009.

Methods:

The study population comprised Olmsted County, Minnesota residents with incident RA (age ≥18 years, 1987 ACR criteria met in 1980-2009) and non-RA subjects from the same underlying population with similar age, sex and calendar year of index. All subjects were followed until death, migration, or 04/30/2019. Incident HF was defined using Framingham criteria. Patients with HF prior to RA incidence/index date were excluded. Cox proportional hazards models were used to compare incident HF events by decade, adjusting for age, sex and cardiovascular risk factors: smoking, obesity, diabetes mellitus, hypertension, dyslipidemia. Cumulative incidence of HF adjusted for death was also computed.

Results:

The study included 905 patients with RA (mean age 55.9 years; 69% female; median follow-up 13.4 years). The 10-year cumulative incidence of HF in RA cohort in the 1980s was 8.5% (95%CI 5.3-13.6%), 1990s was 10.8% (95%CI 7.7-15.1%), and 2000s was 7.1% (95%CI 4.9-10.3%). There was no difference in incidence of HF in 1990s (hazard ratio [HR] 0.91, 95% Confidence Interval [CI] 0.62-1.35) and 2000s (HR 0.73; 95%CI 0.46-1.18) compared to 1980s. Patients with incident RA were then compared to 903 individuals without RA (mean age 56.0 years; 69% female; median follow-up 13.8 years). The 10-year cumulative incidence of HF in these individuals in the 1980s was 7.4% (95%CI 4.5-12.3%), 1990s was 7.5% (95%CI 4.9-11.3%), and 2000s was 7.3% (95%CI 5.0-10.7%). Similar to RA, there was no statistically significant difference in incidence of HF in 1990s (HR 0.96, 95%CI 0.60-1.51) and 2000s (HR 0.75, 95%CI 0.44-1.30) compared to the 1980s. When comparing the risk of HF in RA and non-RA subjects, patients with RA in 2000s had no excess in HF risk as compared to the general population (HR 1.14, 95%CI 0.73-1.78, Figure 1). This is in contrast to the 2-fold excess risk of HF in patients with RA in 1980s (HR 2.20, 95%CI 1.44-3.34) and ~1.5-fold increase in risk of HF in 1990s (HR 1.54, 95%CI 1.04-2.29).

Figure 1.

Cumulative incidence of any HF event in RA and non-RA patients by decade of RA incidence/index

Conclusion:

We found a reduction in excess HF risk in patients with RA compared to individuals without RA in 2000s compared to 1980s. There were no statistically significant changes in incidence of HF in patients with RA and in individuals without RA over time. More studies are needed to understand the reasons and implications of these trends.

References:

[1]Nicola PJ, et al. The risk of congestive heart failure in rheumatoid arthritis: a population-based study over 46 years. Arthritis Rheum 2005;52:412–20.

Acknowledgements:

This work was supported by a grant from the National Institutes of Health, NIAMS (R01 AR46849) and NHLBI (HL120859). Research reported in this publication was supported by the National Institute of Aging of the National Institutes of Health under Award Number R01AG034676. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Disclosure of Interests:

Elena Myasoedova: None declared, John M Davis III Grant/research support from: Pfizer, Sara Achenbach: None declared, Kerry Wright: None declared, Reto Kurmann: None declared, Rekha Mankad: None declared, Veronique Roger: None declared, Cynthia S. Crowson: None declared

IVF outcomes in patients with a history of bariatric surgery: a multicenter retrospective cohort study

STUDY QUESTION

How does a history of dramatic weight loss linked to bariatric surgery impact IVF outcomes?

SUMMARY ANSWER

Women with a history of bariatric surgery who had undergone IVF had a comparable cumulative live birth rate (CLBR) to non-operated patients of the same BMI after the first IVF cycle.

WHAT IS KNOWN ALREADY

In the current context of increasing prevalence of obesity in women of reproductive age, weight loss induced by bariatric surgery has been shown to improve spontaneous fertility in obese women. However, little is known on the clinical benefit of bariatric surgery in obese infertile women undergoing IVF.

STUDY DESIGN, SIZE, DURATION

This exploratory retrospective multicenter cohort study was conducted in 10 287 IVF/ICSI cycles performed between 2012 and 2016. We compared the outcome of the first IVF cycle in women with a history of bariatric surgery to two age-matched groups composed of non-operated women matched on the post-operative BMI of cases, and non-operated severely obese women.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The three exposure groups of age-matched women undergoing their first IVF cycle were compared: Group 1: 83 women with a history of bariatric surgery (exposure, mean BMI 28.9 kg/m2); Group 2: 166 non-operated women (non-exposed to bariatric surgery, mean BMI = 28.8 kg/m2) with a similar BMI to Group 1 at the time of IVF treatment; and Group 3: 83 non-operated severely obese women (non-exposed to bariatric surgery, mean BMI = 37.7 kg/m2). The main outcome measure was the CLBR. Secondary outcomes were the number of mature oocytes retrieved and embryos obtained, implantation and miscarriage rates, live birth rate per transfer as well as birthweight.

MAIN RESULTS AND THE ROLE OF CHANCE

No significant difference in CLBR between the operated Group 1 patients and the two non-operated Groups 2 and 3 was observed (22.9%, 25.9%, and 12.0%, in Groups 1, 2 and 3, respectively). No significant difference in average number of mature oocytes and embryos obtained was observed among the three groups. The implantation rates were not different between Groups 1 and 2 (13.8% versus 13.7%), and although lower (6.9%) in obese women of Group 3, this difference was not statistically significant. Miscarriage rates in Groups 1, 2 and 3 were 38.7%, 35.8% and 56.5%, respectively (P = 0.256). Live birth rate per transfer in obese patients was significantly lower compared to the other two groups (20%, 18%, 9.3%, respectively, in Groups 1, 2 and 3, P = 0.0167). Multivariate analysis revealed that a 1-unit lower BMI increased the chances of live birth by 9%. In operated women, a significantly smaller weight for gestational age was observed in newborns of Group 1 compared to Group 3 (P = 0.04).

LIMITATIONS, REASONS FOR CAUTION

This study was conducted in France and nearly all patients were Caucasian, questioning the generalizability of the results in other countries and ethnicities. Moreover, 950 women per group would be needed to achieve a properly powered study in order to detect a significant improvement in live birth rate after bariatric surgery as compared to infertile obese women.

WIDER IMPLICATIONS OF THE FINDINGS

These data fuel the debate on the importance of pluridisciplinary care of infertile obese women, and advocate for further discussion on whether bariatric surgery should be proposed in severely obese infertile women before IVF. However, in light of the present results, infertile women with a history of bariatric surgery can be reassured that surgery-induced dramatic weight loss has no significant impact on IVF prognosis.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by unrestricted grants from FINOX-Gédéon Richter and FERRING Pharmaceuticals awarded to the ART center of the Clinique Mathilde to fund the data collection and the statistical analysis. There are no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

NCT02884258.

Characterization of a rat model of moderate liver dysfunction based on alpha-naphthylisothiocyanate-induced cholestasis

Plasma amino acid level changes occur in mild, moderate and severe stages of liver injury in human patients. In animal models, however, data are mainly restricted to severe liver injury models in rats. Here we present the characterization of a rat model of moderate liver dysfunction secondary to alpha-napthylisothiocyanate (ANIT)-induced cholestasis. Rats treated with 30 mg/kg/day ANIT for 3 weeks exhibited a time-dependent increase in plasma alanine aminotransferase (ALT), aspartate aminotransferase (AST) and bilirubin levels and a decrease in albumin concentration. According to a liver dysfunction evaluation based on the human Child-Pugh-Score, animals developed a moderate liver dysfunction in the first two weeks of ANIT treatment, while only a mild dysfunction was observed at the end of week 3 despite ongoing ANIT administration. Univariate analysis of branched-chain amino acid plasma levels indicated that reduced levels of branched chain amino acids were associated with the ANIT treatment. These data may set the stage for further research of amino acid disturbances and requirements in non-severe cholestasis.

An efficient scheme for sampling fast dynamics at a low average data acquisition rate

We introduce a temporal scheme for data sampling, based on a variable delay between two successive data acquisitions. The scheme is designed so as to reduce the average data flow rate, while still retaining the information on the data evolution on fast time scales. The practical implementation of the scheme is discussed and demonstrated in light scattering and microscopy experiments that probe the dynamics of colloidal suspensions using CMOS or CCD cameras as detectors.

State of the art of endoscopic frontal sinus cerebrospinal fluid leak repair

Frontal sinus cerebrospinal fluid leaks are rare and their surgical management is difficult. Up until recently, they could only be treated by open surgery with an osteoplastic flap. With the development of endoscopic surgery, less invasive techniques such as an exclusive endoscopic approach can now be used, ensuring a simpler postoperative course. However, these techniques require a thorough knowledge of frontal sinus anatomy and endoscopic CSF leak repair. This knowledge is essential both to ensure closure of the CSF leak and to preserve frontal sinus patency.

Bulk and interfacial stresses in suspensions of soft and hard colloids

We explore the influence of particle softness and internal structure on both the bulk and interfacial rheological properties of colloidal suspensions. We probe bulk stresses by conventional rheology, by measuring the flow curves, shear stress versus strain rate, for suspensions of soft, deformable microgel particles and suspensions of near hard-sphere-like silica particles. A similar behaviour is seen for both kinds of particles in suspensions at concentrations up to the random close packing volume fraction, in agreement with recent theoretical predictions for sub-micron colloids. Transient interfacial stresses are measured by analyzing the patterns formed by the interface between the suspensions and their solvent, due to a generalized Saffman-Taylor hydrodynamic instability. At odds with the bulk behaviour, we find that microgels and hard particle suspensions exhibit vastly different interfacial stress properties. We propose that this surprising behaviour results mainly from the difference in particle internal structure (polymeric network for microgels versus compact solid for the silica particles), rather than softness alone.

[Morbidity of neck dissection submuscular recess (sublevel IIb) in head and neck cancer]

OBJECTIVES

The impact of neck dissection on quality of life has often been considered less important than the oncological control. Dissection of level IIb doesn't improve oncologic control everytime, knowing that an injury of the spinal nerve can occur. The aim of our study was to assess the impact of neck dissection including level IIb on shoulder function and quality of life in N0 patients.

MATERIALS AND METHODS

Fifteen patients with squamous cell carcinoma of the upper aerodigestive tract, clinical and radiological NO, were included. They were assessed by validated scales (QLQ-C30, H&N35 and DASH) and they underwent an examination of the shoulder.

RESULTS

Almost half of the patients had pain in the shoulder. The functional scale score QLQ-C30 was statistically more altered (49.7%) than that of patients with cancer in general (74.9%, p = 0.00016) and of the general population 60 to 69 years (85.4%, p = 0).

CONCLUSION

The results of our study underscore the morbidity on shoulder function after neck dissection. These findings, combined with the low prevalence of occult lymph node metastases in level IIb among T1-T2 patients, must question the systematic inclusion of this level in neck dissection.

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

[Sacrospinous colpopexy complications]

OBJECTIVE

To evaluate complications of sacrospinous ligament fixation.

DESIGN

Monocentric retrospective study.

SETTING

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

PATIENTS AND METHODS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

DISCUSSION AND CONCLUSION

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

[Results of hysteroscopic myomectomy]

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

[Complications of operative hysteroscopy]

OBJECTIVES

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

[Open laparoscopy: analysis of complications due to first trocar insertion]

OBJECTIVE

To evaluate the complications of open laparoscopy during the set-up of laparoscopy in gynecologic surgery.

DESIGN

Retrospective study performed between February 1994 and January 2001 in a University Centre.

PATIENTS AND METHODS

1,562 patients underwent open laparoscopies. Procedures were performed by 8 gynaecological surgeons. Peri- and postoperative complications were assessed and analysed.

RESULTS

Major injuries concerned gastrointestinal tract: 2 perforations with immediate diagnosis and one postoperative occlusion treated by delayed laparotomy (0.19%). No death occurred. No vascular injuries and no bladder complications were noted.

CONCLUSION

We recommend open laparoscopy because of its innocuity and easiness. Advantages concern decrease of major vascular injuries and early recognition of bowel injuries.

Risk of discovering endometrial carcinoma or atypical hyperplasia during hysteroscopic surgery in postmenopausal women

STUDY OBJECTIVE

To assess the risk of diagnosing endometrial carcinoma or atypical hyperplasia in tissue resected during hysteroscopy performed for intrauterine pathology presumed benign in postmenopausal women.

DESIGN

A single-center prospective study (Canadian Task Force classification II-2).

SETTING

Department of Gynecology, La Conception Hospital, Marseille, France.

PATIENTS

Three hundred twenty-five women with intrauterine pathology, presumed benign, causing postmenopausal bleeding or bleeding related to hormone replacement therapy.

INTERVENTION

All women had an endometrial biopsy after diagnostic hysteroscopy to exclude endometrial carcinoma or atypical hyperplasia. Then they underwent hysteroscopic surgical resection (203, 62.5%) or endometrial ablation (122, 37.5%).

MEASUREMENTS AND MAIN RESULTS

Two cases each (0.6%) of endometrial carcinoma and endometrial atypical hyperplasia were discovered that were missed by preoperative evaluations.

CONCLUSION

Outpatient hysteroscopy and endometrial biopsy do not eliminate the finding of carcinoma or endometrial atypical hyperplasia, as these disorders may be discovered during hysteroscopic surgery.

Port-site recurrence following laparoscopic para-aortic lymphadenectomy for squamous carcinoma of the cervix

A port site tumour recurrence (PSR) followed laparoscopic para-aortic lymphadenectomy in a 46-year-old woman with stage IIb squamous carcinoma of the cervix. It occurred at the site used for removal of affected lymph nodes 7 months after surgery and completion of radiation and chemotherapy. It was associated with an increase in the size of tumour.

Endometrial biopsy during outpatient hysteroscopy: evaluation and comparison of two devices

OBJECTIVE

Association of office hysteroscopy with outpatient endometrial biopsy is interesting to evaluate correctly endometrium. Purpose of this study was to evaluate and compare two endometrial biopsy devices during outpatient hysteroscopy, based on effectiveness and tolerance of the procedure.

STUDY DESIGN

A single blind, randomised prospective study.

RESULTS

200 patients were randomised into two groups following outpatient hysteroscopy: 100 were biopsied with Vacurette and 100 biopsed with Pipelle. Pipelle was less painful compared to Vacurette (1.1+0.2 versus 1.6+0.3; P<0.001), no matter hormonal status (1+0.3 versus 2+0.6; P<0.001 in premenopausal subgroup and 1+0.3 versus 1.4+0.3; P<0.001 in postmenopausal subgroup). Vacurette was more effective than Pipelle (64/100 versus 48/100; P=0.02), in case of normal or hypertrophic endometrium (56/72 (77%) versus 40/65 (61%); P=0.04) but not in case of atrophic endometrium (8/28 (29%) versus 8/35 (23%); P=0.6). Among the 112 patients with adequate sample, histologic results were normal, except for three cases of endometrial hyperplasia. Among the 88 patients with inadequate sample, 47 (53%) presented an atrophic endometrial aspect at hysteroscopy, whereas 41 (47%) were considered as normal.

CONCLUSIONS

Vacurette was more effective though more painful than Pipelle. Both instruments were, however, well tolerated. Both instruments were not very effective in case of atrophic endometrium. Outpatient hysteroscopy combined with endometrial biopsy may help avoid further investigations.

[Vaginal hysterectomy:apropos of a series of 1008 interventions]

STUDY AIM

The aim of this study was to analyse our vaginal hysterectomies performed for prolapsed uterus and non prolapsed uterus with benign disease. For the latter indication, a comparison was made with abdominal hysterectomy.

PATIENTS AND METHODS

From february 1986 to december 1998, 1008 vaginal hysterectomies were performed in our department: 219 for prolapsed uterus and 789 for non prolapsed uterus with benign disease. During the same time, 217 abdominal hysterectomies were performed for non prolapsed uterus with benign disease.

RESULTS

Intra-operative and post-operative complications had the same rates in the two groups. Owing to the low number of abdominal hysterectomies, we cannot draw a valuable conclusion. The study of the literature shows in this field an advantage for the vaginal hysterectomy; mean time hospitalization was shorter in the vaginal group.

CONCLUSION

Advantages of vaginal hysterectomy are multiple: aesthetic, shorter hospitalization, quicker recovery. The low rate of vaginal hysterectomy on non prolapsed uterus with non malignant disease is linked with the lack in training of surgeons for the vaginal approach. In these cases, a rate of 70% is a realistic one in a well trained hospital center.

Vaginal birth following two previous cesarean sections

OBJECTIVE

To evaluate the management of vaginal delivery among women with two previous cesarean sections. The maternal and fetal morbidities of this attitude were studied.

SETTING

University hospital.

DESIGN

Retrospective study made over 6 years, from January 1st 1990 to December 31st 1995.

PATIENTS

Among 180 patients with two uterine scars, 96 patients with cephalic presentation and normal pelvic dimensions were allowed trial of labor.

RESULTS

The rate of vaginal birth following trial of labor was 65.6%. Three patients had an uterine scar dehiscence; among them, one hysterectomy was performed for haemorrhage with uterine atony. Neonatal issue was always favorable. Twenty-two newborns had superior birthweights compared to those born from the preceding cesarean section.

CONCLUSION

Trial of labor following two previous cesarean sections is acceptable in the majority of cases. It leads to a high vaginal delivery rate and low maternal and fetal morbidity.

Hysteroscopic resection of endometrial polyps: a study of 195 cases

OBJECTIVE

To ascertain the therapeutic efficiency of hysteroscopic resection for the treatment of endometrial polyps in women with abnormal uterine bleeding and postmenopausal metrorrhagia.

SETTING

University hospital.

DESIGN

Retrospective consecutive patient follow-up.

MATERIAL AND METHODS

From 1987 to 1997, 195 patients with haemorrhagic endometrial polyps were treated with hysteroscopic resection in our department.

RESULTS

Five complications occurred, but no major complications were noted. A total of 89.2% of the patients remained in contact after hospitalization. After long term follow-up (5.2 years), successful results were obtained in 80% of the patients with polyp resection without associated endometrial ablation. Further surgery (hysterectomy) was required in only five women.

CONCLUSION

Transcervical resection is the gold standard for treatment of endometrial polyps.

[Value of endocervical margin examination of conization specimens. Prospective study conducted on 150 patients]

OBJECTIVE

To assess the usefulness of frozen sections (FS) on endocervical margin in surgical conization or loop electrosurgical specimens.

MATERIAL AND METHODS

In a prospective study, 150 patients were treated from October 1995 to December 1997: 69 cases without FS, 81 cases with FS. CIN on frozen section resulted in an immediate additional resection.

RESULTS

In the group without FS, 13 patients had involved endocervical margin by high-grade CIN (18.8%). Frozen section was impossible in a conization specimen that was too short. FS revealed 64 normal glandular epitheliums, seven squamous metaplasias in which two lesions were under-evaluated (being in fact CIN on permanent sections), eight high-grade CIN followed by additional resection in six cases and two invasive carcinomas. Endocervical margin on additionals section were always free of disease. The rate of failure was 2.6% among 77 cases. This rate corresponded to two under-evaluations. Invasive carcinoma and CIN without additional resection were excluded because frozen section only allowed a peroperative diagnosis. The average height of the cone and the rate of complications were similar. Repeat surgery was necessary in nine cases in the group without frozen section, in which five showed residual lesions, absent in the other group.

CONCLUSION

The ultimate histological interpretation was never difficult after frozen section. This method permits reduction of cases with involved cone margin and residual lesions and, despite some limitations, it may be useful for surgical management.

[Conization with positive margins: what strategy should be adopted?]

OBJECTIVE

To define recommended treatment in cases of positive margins on cone biopsy specimens.

PATIENTS AND METHODS

This single-center retrospective study concerned 220 conizations performed between January 1996 and June 1998. The results of 70 conizations (31.8%) with positive margins were analysed. There were 32 cold knife conizations (mean age: 43 years) and 38 conizations by the loop electrosurgical excision procedure (mean age: 33 years).

RESULTS

Mean depth of conization was 15.94 mm for cold knife conization and 10.08 mm for loop electrosurgical conization. Fifteen patients were excluded (5 with invasive cancer and 10 were lost to follow-up). This study included 55 patients with a mean 12-month follow-up. Six underwent hysterectomy for mini-invasion on the specimen or advanced age. Eleven underwent a second conization (followed by hysterectomy in 2 cases). The other 38 patients were submitted to simple surveillance with cervico-vaginal cytology and colposcopic examination. The rate of residual lesions (cervical intra-epithelial neoplasia: CIN 3) after conization with positive margin was 14.5% (n = 8).

CONCLUSION

Residual persistent dysplasia is not present in all patients after conization with positive margins. Cytology and colposcopy allow detection of dysplasia, indicating the need for a second conization. In women with no desire for further pregnancy, systematic repeat surgery must be recommended.

Hysteroscopic metroplasty for septate uterus and repetitive abortions: reproductive outcome

OBJECTIVES

The aim of this study is to assess fertility outcome and obstetrical prognosis of 63 patients after hysteroscopic section of uterine septa.

MATERIALS AND METHODS

This is a retrospective study about 63 patients consulting for septate uterus and repeated pregnancy loss or abnormal fetal presentation between January 1988 and December 1996 in La Conception hospital in Marseille. Septal lysis was performed with microscissors or resectoscope. Statistical analysis was performed using the CHI2-test.

RESULTS

The anatomical result was considered satisfactory in 57.1% of cases. Forty-five pregnancies were obtained, two after an IVF-program in 56 patients. Twenty-eight living children were born: twenty-six at term. Twenty patients delivered normally. Two women are still pregnant. Obstetrical prognosis of these patients is statistically improved by the treatment (P=0.001).

CONCLUSION

Obstetrical prognosis of patients presenting repeated pregnancy loss and septate uterus is statistically improved by hysteroscopic metroplasty.

[Evaluation of two methods for endometrial sampling during diagnostic hysteroscopy]

OBJECTIVE

To compare two endometrial sampling devices, pipelle and vacurette, performed during hysteroscopy, based on the quality of material obtained and pain during the sampling.

PATIENTS AND METHODS

During the period from 01.03.96 to 01.12.97, 200 patients were consecutively randomized in a single blind prospective study. Efficacity was evaluated on the quality of material obtained and pain was graded on a scale of 0 to 5.

RESULTS

On the average the Vacurette was more painful (1.6 vs 1.1, p = 0.01). Vacurette biopsy was more effective than pipelle biopsy (64% vs 48%, p = 0.05). There was a significative difference of efficacity in the post-menopausal group (34% vs 13%, p = 0.05), but not in the pre-menopausal group (76% vs 64%, p > 0.05). When hysteroscopy diagnosed endometrial atrophy, there was no significative difference of efficacity (29% vs 23%, p > 0.05), whereas vacurette was significatively more effective when there was an other hysteroscopy diagnosis (78% vs 62%, p = 0.05). Both procedures were less effective in post-menopausal women (p = 0.001), and in case of endometrial atrophy (p = 0.001).

CONCLUSION

Both procedures were acceptable during ambulatory hysteroscopy. In our study, vacurette was more painful than pipelle. Vacurette was more effective but insufficient tissue for histologic evaluation was important in both procedures. This might be explained by the population included and the histologic method used.

[The disinfection of non-autoclavable hysteroscopes in gynecology. Proposition of a protocol and organization of its management]

Iatrogenic infections may result from diagnostic hysteroscopy in case of non autoclavable equipment (such as fibrohysteroscopes) and because of new infectious agents (such as HIV, hepatitis, ...). The equipment should be completely and thoroughly disinfected according to the manufacturer's instructions to prevent infectious complications.

[Vaginal hysterectomy for non-prolapse uterus]

Vaginal hysterectomy in the treatment of non prolapsed uterus without malignant disease is a well codified technique. Per operative complications, post operative morbidity are less frequent and less serious than by abdominal surgery and convalescent time is less extended. Financial cost is lower compared with laparoscopic hysterectomy. The successful result of the vaginal way is determined by anatomic factors: volume and mobility of the uterus, accessibility of the vagina, but above all by the training of the surgeons. A rate of seventy per cent of hysterectomies performed by the vaginal way in the case of this indication is a realistic aim in a hospital center.

Long-term prognostic value of positive peritoneal washing in colon cancer

BACKGROUND

We examined the potential prognostic value of free malignant cells in the peritoneal cavity of patients with colon adenocarcinoma.

METHODS

In 1991 and 1992, 88 patients underwent peritoneal washing with cytologic analysis immediately before elective colon resection for adenocarcinoma with no evidence of peritoneal metastases. Peritoneal washing fluid was collected before abdominal exploration, centrifuged immediately, and stained with the May-Grünwald-Giemsa and Harris Shorr methods. Malignancy was defined as recommended by Papanicolaou.

RESULTS

Free malignant cells in peritoneal fluid (positive peritoneal washing) were found in 25 of 88 (28%) patients (Dukes A, 0 of 11; Dukes B, 10 of 31; Dukes C, 11 of 37; Dukes D, 4 of 9). The positivity rate was 24 of 75 (32%) among patients with tumours involving the serous layer and 1 of 13 (8%) among the others (P = 0.0989). With a follow-up of 66.7 to 78.7 months the 5-year survival rates were 48% (95% confidence interval, 28.4-67.6) and 68% (95% CI, 56.2-79.8) among patients with positive and negative peritoneal washing, respectively (P = 0.09). Positive peritoneal washing was not significantly associated with survival in multivariate analysis.

CONCLUSION

The presence of free malignant cells in the peritoneal cavity of patients with colon cancer provided no further prognostic information relative to the Dukes classification in this study. Nevertheless, further study is needed, particularly in a larger series of Dukes B patients, for whom a new prognostic factor would be useful for deciding adjuvant therapy.

[Impact of adenomyosis on results of endometrial ablations]

The authors report the results of a retrospective series concerning 121 patients who presented abnormal uterine bleeding resistant to progestogen therapy. These patients were adenomyosis carriers and who underwent loop endometrial ablation. Over a maximum period of 8 years, the success rate was 56% following one endometrial resection and 67% following one or two resections. The study recorded a repeat resection level of 11%. Seventeen hysterectomies (19%) were performed because of the recurrence of abnormal uterine bleeding. These results are comparable to those observed in endometrial ablation performed for menorrhagia, all benign etiology included. Adenomyosis does not appear to be a factor in the failure of endometrial ablation, except in the case of deep adenomyosis which is difficult to diagnose pre-operatively.

Laparoscopic surgery in gynecology: randomized prospective study comparing pneumoperitoneum and abdominal wall suspension

OBJECTIVE

To compare laparoscopic surgery using insufflation of carbon dioxide gas with laparoscopic surgery using abdominal wall retractor in gynecology.

SETTING

University hospital.

DESIGN

Prospective randomized study.

MATERIAL AND METHODS

Fifty-one patients were assigned to the gasless laparoscopy group, and 52 patients were assigned to the laparoscopy group with pneumoperitoneum. Patients presented with ovarian cyst, endometriosis, acute salpingitis, hydrosalpinx and extra-uterine pregnancy.

RESULTS

No severe complications were noted. One conversion to laparotomy was performed in each group. Eight gasless laparoscopic procedures were converted into laparoscopy with pneumoperitoneum; difficulties appeared in patients with adhesions following laparotomy and in cases of unsatisfactory exposure of the pelvis. No differences appeared between the two groups in terms of complications, quality of the operative sequelae, and duration of hospitalization.

CONCLUSION

Gasless surgery is a recent technique and progress in modifying the equipment is necessary to reduce conversions.

Brachytherapy and vaginal hysterectomy for low-stage uterine cervix carcinoma

OBJECTIVE

The aim of this study was to assess safety and efficiency of a limited vaginal hysterectomy after brachytherapy in patients with early uterine cervix carcinoma without unfavorable prognostic factors. All tumors were less than 1.5 cm in diameter.

MATERIAL AND METHODS

Between October 1992 and December 1995, 22 patients with low-stage uterine cervix carcinoma (stage Ia2 with vascular invasion, 3 cases; stage Ib1, 19 cases) were included in this study. Patients underwent the following procedures: single utero-vaginal brachytherapy after a previous negative laparoscopic lymphadenectomy (median number of lymph nodes: 12) followed 6 weeks later by a limited vaginal hysterectomy.

RESULTS

Two mild intraoperative complications were noted. Venous hemorrhage (100 cc) occurred in one patient during lymphadenectomy and another patient experienced bladder injury during hysterectomy. These two complications were successfuly controlled with no need for laparotomy. Only one late complication was observed and was evaluated as a bladder grade G2(b) according to the Franco-Italian glossary. With a 30 (22-50) month follow-up, no recurrence was reported.

CONCLUSION

These results appear promising in patients with very early cervix carcinoma but remain to be confirmed on a larger scale.

[Hysteroscopic myomectomy. Functional results with an average follow-up of 6 years]

OBJECTIVE

In 1995, we presented our experience in hysteroscopic resection of hemorrhagic submucous fibroids in 196 patients. The objective of the present work was to analyze functional outcome three years later.

PATIENTS

One hundred ninety-six patients with abnormal uterine bleeding were treated between 1987 and 1993. Equipment, techniques, characteristics of the procedures and early results were detailed in the previous article.

RESULTS

With a mean follow-up of 73 months (range 50,104), results were: 13.8% of the patients were lost to follow-up; 68.4% had symptomatic improvement and failure was observed in 17.8% (subsequent hysterectomy in 12.7%). Forty-nine patients had repeat resection in this series; 61 became menopausal after surgery, and 21 were taking hormone replacement therapy with good results.

CONCLUSION

Developed as an alternative to hysterectomy, operative hysteroscopy has proven to be a safe and effective procedure. This treatment modality appears to give satisfactory long-term results, with a low rate of complications.

[Contribution of hysteroscopic surgery for the treatment of postmenopausal metrorrhagia]

OBJECTIVES

Determine the effectiveness of hysteroscopic surgery in persistent postmenopausal bleeding.

PATIENTS AND METHODS

Transcervical resection was performed in 176 women between the ages of 46-74 years. A benign cause was noted in 135 cases (polyps in 80 and submucous fibroids in 55); 37 patients had no significant disease and 4 had endometrial atypical hyperplasia missed in the preoperative evaluation. Patients underwent resection of polyp, resection of fibroid or endometrial ablation. Major operative complications were rare and included 3 perforations and one case of fluid overload. Patients were followed for 1-10 years after treatment (mean follow-up 52 months).

RESULTS

167 patients completed the study. Clinical manifestations disappeared in 85.2% of the patients; 15 patients had hysterectomy after the hysteroscopic procedure and 11 had repeat transcervical resection.

CONCLUSION

Hysteroscopic treatment can be effective in carefully selected patients with postmenopausal bleeding or abnormal uterine bleeding on hormone replacement therapy. The operative criteria should take the causes of bleeding and not just the age of patient into account.

[Role of diagnostic hysteroscopy in the exploration of postmenopausal metrorrhagia]

DIAGNOSIS

Diagnostic hysteroscopy is an effective method for identifying the causes of postmenopausal bleeding. It evaluates the uterine cavity and visualizes pathologic conditions such as endometrial polyps, submucous fibroids, and focal endometrial abnormalities including adenocarcinoma and its precursors.

FURTHER INFORMATION

With directed biopsy, diagnostic hysteroscopy also ensures the recognition of these lesions.

[Surgical hysteroscopy in the treatment of septate uterus: systemic treatment or selective indications]

OBJECTIVES

A retrospective study to evaluate the fertility rate after endoscopic hysteroplasty in the case of a septate uterus.

METHOD

From 1st January 1988-31st December 1996, 93 patients showing a septate uterus were treated by endoscopic hysteroplasty. The hospitalisation is short: one day surgery or out office. A control of uterine cavity by hysteroscopy did next to two months.

RESULTS

Patients were evaluated after a period in excess of 6 months (6 months-8 years). 63 pregnancies were achieved amongst the 84 patients to be reviewed (75%). The fertility rate achieved is higher amongst infertile patients (80.3%) compared with that of sterile patients (64%).

CONCLUSION

In the presence of septate uterus the endoscopic hysteroplasty is an efficient treatment in the case of secondary infertility and of unexplained sterility.

[Hysteroscopic surgery and fertility]

In the treatment of uterine lesions associated with infertility, such as septate uterus and synechiae, hysteroscopic surgery has replaced conventional abdominal surgery. Hysteroscopic metroplasty improves obstetrical prognosis in patients with septate uterus. Advantages of hysteroscopy are low morbidity rate, decreased hospitalization time, and absence of hysterotomy. Hysteroscopic surgery of synechiae allows to achieve good anatomical results in most of the cases. The first risk of this surgery is perforation. However, obstetrical results are uneven; pregnancy rates are low in cases of complex synechiae. Endometrial ablation is performed in patients presenting with abnormal uterine bleeding after failure of progestin therapy. Pregnancies following endometrial ablation have been described; term deliveries are still exceptional.

Internal bioartificial liver with xenogeneic hepatocytes prevents death from acute liver failure: an experimental study

OBJECTIVE

To demonstrate that a bioartificial liver, using allogeneic or xenogeneic hepatocytes protected from rejection by a semipermeable membrane, could prevent death from acute liver failure.

SUMMARY BACKGROUND DATA

An implantable bioartificial liver using isolated hepatocytes could be an alternative to orthotopic liver transplantation to treat patients with acute liver failure. It could serve either as a bridge until liver transplantation or as the main treatment until recovery of the native liver. However, allogeneic or xenogeneic hepatocytes that could be used in clinical applications are spontaneously rejected.

METHODS

Acute liver failure was induced in rats by 95% liver resection. Twenty-five million hepatocytes harvested in rats (allogeneic) or guinea pigs (xenogeneic) were encapsulated in a semipermeable membrane to protect them from rejection. The hollow fibers containing hepatocytes were transplanted into the peritoneum of recipient rats. Survival rates were compared between rats transplanted or not with hepatocytes.

RESULTS

In groups not transplanted with viable hepatocytes, 73% to 93% of rats died after 95% liver resection. The mortality rate was reduced to 39% in rats transplanted with allogeneic hepatocytes and 36% in rats transplanted with xenogeneic hepatocytes. The bioartificial liver could be removed 1 month after transplantation, when regeneration of the native liver was complete. Allogeneic and xenogeneic hepatocytes remained viable.

CONCLUSIONS

The implantable bioartificial liver was able to prevent death in this model of acute liver failure. This could be an important step toward clinical application of the method.

[Vaginal myomectomy]

The authors present a retrospective study of 26 patients who have benefited from vaginal myomectomy after culdotomy in the Conception hospital in Marseille between 1992 and 1997. The myomectomy whom technic is described, was performed unically through the vagina or laparoscopically assisted. The mean operating time was 94 mn. The myoma mean weight was 184.3 g. Three patients experienced an abdominal surgery, twice because of a vaginal inaccessness. The immediate and mean-term post-operative period was uncomplicated in most cases. For screened patients, vaginal myomectomy appears as an interesting alternative to abdominal or laparoscopic surgery.