Vers une simplification de la technique de césarienne : suture péritonéale ou non ?

Objectives

To assess the postoperative morbidity of a technique for caesarean section without closing the visceral and parietal peritoneum.

Patients and methods

We conducted a prospective cohort study randomized 252 patients over a period of four months (from March 1 to June 30, 2009). We studied the early postoperative morbidity.

Results

Among the 252 patients, 137 were included in the group “with peritonisation” and 115 in the group “without peritonisation”. Clinical and hematology maternal characteristics were comparable in both groups. The duration of intervention was reduced significantly in the absence of peritonisation (31.1 instead of 41.4 minutes; P < 0.001). The postoperative pain was less but not significant between h0 and h12, however it is significant at h18, h24and h30 in the absence of peritonisation (respectively 2.37 versus 2.81; P = 0.030; 1.98 versus 2.37; P < 0.001 and 1.38 versus 1.72; P = 0.018). Resumption of transit was significantly faster “without peritonisation” (24.3 versus 24.7 hours; P < 0.001). However, there is no significant difference between the two groups as regards the immediate postoperative complications.

Conclusion

The absence of visceral and parietal peritoneum shortens the operative time and favors an earlier resumption of transit. It also decreases pain symptoms. We therefore recommend not to suture the parietal and visceral peritoneum during cesarean section.     

Evolución del porcentaje de episiotomía en un hospital comarcal entre los años 2003–2009. Factores de riesgo de los desgarros graves de periné

Objective

The primary objective of this paper is to present the evolution of the episiotomy rate between the years 2003-2009, following a policy of restrictive use and its possible influence on the rate of severe lacerations and perinatal morbidity in the short term.

Methods

This is a retrospective study based on a cohort made up of women who gave birth in our hospital (9023 women). The valued parameters are: changes in the episiotomy rate, percentage of severe perineal tears according to the use of episiotomy or not. Normal vaginal deliveries versus instrumental ones and the type of instrumental delivery. Apgar score below 7 at five minutes. A multivariable logistic regression was performed in order to assess the relationship between risk factors and the incidence of severe tears.

Results

The episiotomy rate ranged between 40.37% in 2003 and 8% in 2009, the downward trend was statistically significant. The rate of severe tears remained between 0.49% and 1.04% that change was not statistically significant. There was no significant variation in the rate of Apgar score less than 7 at 5 minutes. The odds ratio (OR) of having a serious perineal tear is 2.99 (95% CI 1.47 to 6.05) in women who had an episiotomy compared with those that did not have it, the 2.40 (95% CI 1.16 to 4.99) in the instrumental delivery versus eutocic delivery and the 6.43 (95% CI 1.50 to 27.49) in forceps deliveries compared with vacuum deliveries.

Conclusions

Over a period of 7 years the episiotomy rate was reduced by 80% without modifying the rate of serious perineal tears, and the short-term perinatal morbidity remained constant.     

Carcinoma ductal in situ, ¿factor de riesgo de mastectomía?

Objective

To determine the histological or immunohistochemical characteristics of ductal carcinomas in situ (DCIS) that could influence margin status at first surgery and at final surgery.

Material and methods

We retrospectively studied the 485 breast carcinomas diagnosed in 2003, 2004 and 2005 at the Doce de Octubre Hospital (Madrid), of which 54 (11.1%) were DCIS and 280 (57.7%) were invasive ductal carcinomas (IDC).

Results

Only 10% of DCIS were palpable. DCIS represented 25% of all carcinomas diagnosed by mammographic wire-guided biopsy. We found positive margins on first breast-conserving surgery in 50% of DCIS and in 34% of IDC. Consequently, a second or even a third intervention (for persistently involved margins) was more frequent in DCIS than in IDC. In DCIS higher histological grades were associated with more frequent margin involvement and a higher rate of re-excision with positive margins and mastectomy. The mastectomy rate in DCIS (43%) was higher than that in IDC diagnosed by mammographic wire-guided biopsy (27%), and was similar to that in IDC overall (41%).

Conclusions

Mammographic screening programs have improved the detection of DCIS, but clear margins are sometimes difficult to achieve in this entity, leading to the paradox that women with palpable IDC are able to undergo breast-conserving surgery without compromising prognosis, whereas a mammographically detected DCIS requires mastectomy.     

Facteurs prédictifs de grossesses en cas de transfert de deux embryons au cours de tentatives « Top Quality »

ObjectivesTo identify IVF ± ICSI pregnancy predictive factors during “Top Quality” attempts in case of double embryo transfer.Patients and methodsThree years retrospective study (2007, 2008 and 2009) on parameters and results obtained during IVF ± ICSI defined as “Top Quality” attempts: first or second attempts on less than 35 years old women (age inferior or equal to) with one or two “Top Quality” embryo transfer.ResultsIn case of double embryo transfer, pregnancy predictive factors are (OR [IC 95%], P): average endometrial thickness on start (4.6 [2.9–5.5], P < 0.01), women smoking (4.2 [3.5–4.9], P < 0.01), average stimulation duration (3.4 [2.7–3.9], P < 0.01), average men age (2.2 [1.7–2.5], P < 0.05), gonadotrophins total dose (2.1 [1.1–3.2], P < 0.05) and first rank's attempts (1.6 [1.2–2.5], P < 0.05).Discussion and conclusionAge patient, rank attempts and quality embryo are criteria, which used to guide to a single embryo transfer. Our results incite us to consider other parameters, in particular men age and women smoking status.     

Quoi de neuf depuis le rapport de la HAS ? Bilan de deux ans d’évaluation des implants de renfort prothétique dans le traitement des prolapsus par voie vaginale

The French Health Authorities' (HAS) report of November 2006 concluded that the use of mesh at the time of transvaginal repair of pelvic organ prolapse (POP) should be limited to clinical research. This review intends to analyse and comment the recent data on this topic. A review on PubMed, on a personal database and actualisation until May 2008 has been performed choosing French or English language series concerning prolapse surgery with mesh disposed by the vaginal route. It includes six randomised controlled trials comparing transvaginal repair of POP with or without mesh: four about cystocele, one about rectocele and one about apical prolapse. Both surgical techniques and recurrence criteria are poorly standardised. The four randomised trials focusing on cystocele repair support the anatomical superiority of techniques using mesh, with similar functional results with or without mesh reinforcement. In the other indications, the results remain unclear or controversial. According to the randomised trials, the complications rate, except mesh exposure, is similar with and without mesh. However there are some specific complications when using mesh, such as mesh infection, mesh exposure or shrinkage and visceral extrusion. We recommend using vaginal reinforcement mesh with specific care in selected patients and we suggest some guidelines to be proposed for consensus at concerned French scientific societies.     

Tumeur de la Granulosa de l’ovaire : étude rétrospective à propos de 17 cas

Granulosa cell tumors of the ovary are rare tumor of ovary, included in the sex cord-stromal tumor category, hormone secreting. Seventeen patients with adult-type granulosa cell tumor were identified between 1995 and 2012. All have received surgical treatment first at stage I. Thirty-three percent of the patients relapsed with peritoneal nodules in 68% of the cases, treated surgically and sometimes with complementary therapies, such as chemotherapy, radiotherapy, hormonal treatment. Overall survival and recurrence-free survival were 100% and 58.3%, respectively at 10 years with median time to recurrence of 6 years (4–27). These tumors have therefore a good prognosis and require long-time follow-up. Finally, the prognostic factors of recurrence identified in the literature are FIGO stage, the presence of residual tumor and tumor size.     

Marcadores bioquímicos de cromosomopatía,pregnancy associated plasma proteína-A y fracción β de hormona gonadotropina coriónica humana,como predictores de alteraciones del crecimiento fetal

Objective

The principal aim of this study was to analyze the possible association between prenatal biochemical markers used in prenatal screening for aneuploidy, (pregnancy associated plasma protein A [PAPP-A] and beta-human chorionic gonadotropin) and low birth weight.

Methods

We performed a retrospective cohort study of patients who underwent first trimester screening for aneuploidies. The first and fifth percentiles in our population were calculated for each main variable. We used the chi-square test to assess the relationship between the distinct variables.

Results

A total of 987 patients were included. There were three stillbirths (0.3%) and 10 midtrimester miscarriages (1%). Of 974 live births, body weight was under the 10^th percentile (p) in 84 (8.5%) and was under the third percentile in 21 (2.1%). There was a statistically significant association between low maternal serum PAPP-A and low birth weight.

Conclusion

Our results demonstrate that the biochemical markers used in prenatal screening for aneuploidy also predict low birth weight and can be used in clinical practice to provide an early diagnosis and improve the management of this entity.     

Invasión del espacio linfovascular en lesión intraepitelial escamosa de alto grado de cérvix. ¿Realidad o artefacto?

Background

The loop electro excision procedure is a simple and widely used diagnostic and therapeutic technique in cervical lesions. This procedure is usually performed in the ambulatory setting under local anaesthesia.

Subjects and methods

We describe a case of lymphovascular space invasion detected in the cone biopsy of a high-grade squamous intraepithelial lesion of the cervix.

Conclusions

Although the prognostic significance of LVSI is controversial, its identification precludes conservative treatments.     

Cancer du sein chez la femme jeune de moins de 35 ans en Tunisie : étude rétrospective à propos de 124 cas

ObjectivesOur aim was to report the epidemiological and clinical characteristics of breast cancer in young women and to evaluate the therapeutic results in the central part of Tunisia.Patients and methodsWe report the results of a retrospective study including 124 patients under 35 years old treated for breast cancer between 1995 and 2007 in the Radiotherapy Department of CHU Farhat Hached, Sousse.ResultsThe mean age of our patients was 31.3 years. T2N0, node positive (N+), high grade (SBRII and III) and endocrine responsive tumors were the most frequent. Fourteen patients had metastatic disease. One hundred and fifteen patients underwent a surgical treatment, which was conservative in 35 cases and radical for the others followed by radiotherapy on 114 patients. Chemotherapy, especially based on the FEC protocol, was administrated to 89% of all patients. Forty-five patients received also hormonotherapy. After a median follow-up of 48.5 months, 51 patients remained free of disease. The 5 years overall survival was 67.7%, the 5 years free disease survival was 58.2%.Discussion and conclusionThe 5 years overall survival of breast cancer in young women varies between 55 and 75%, it was 67.7% on our study. These results can be improved by early diagnosis, adapted treatment and nowadays with targeted therapies.